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1. SEWAGE: <br /> Distance to Public Sewers: tea(} J� Connection necessary: Yes No <br /> Does existing septic system comply with San Joaquin County Development Title #549 ? <br /> Yes No Unknow> If no, explain: <br /> Describe septic installation to be installed: <br /> 2. WATER SUPPLY: <br /> Is water supplied by private well: Yes " No Is well proper: Yes` No <br /> State deficiency: <br /> Is well system a Public Water system? Yes No ✓ Is the permit current? Yes No <br /> Does existing or proposed use make this well Public Water: Yes No Is water/well <br /> sampling current: yes No Additional information or comments: <br /> 3. GARBAGE & REFUSE: <br /> Licensed scavenger pick-up: Yes No Service Area No.: Other proposed <br /> disposal method: <br /> Potential problem(s): <br /> 4. FLY MOSQUITO OR VECTOR POTENTIAL: <br /> State possible vector potential and necessary control: <br /> 5. TOILET/BATH FACILITIES: <br /> Number and locations existing: iirS� i �'v�/� Additional <br /> facilities needed: <br /> 6. PREVIOUS OPERATION HISTORY: ` <br /> 7. GENERAL SANITATION: <br /> State any problems not previously noted: �1 <br /> 8. POPULATION DENSITY: <br /> Approximate number of people per square mile: -K'C�" <br /> r -1 <br /> EH 06 Q6 Rev 1/99 <br />