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1. SEWAGE: NOTE: PULL AERMITS (Septic, Well, etc.) MAK6-,IOPIES FOR FILE <br /> Distance to Public Sewers: _ Connection Necessary? ❑ Yes [2"'No <br /> Does Existing Septic System comply with San Joaquin County Development Title? Yes Ej Not <br /> If no,explain: Unknown <br /> Describe Septic System to be installed: <br /> 2. WATER SUPPLY: <br /> Is Water supplied by Private Well ? Yes ❑ No Is well properly sealed and constructed ? Yes ❑ No <br /> Describe deficiency,if any: <br /> Is well system a Public Water system? ❑ Yes [2/No Is Public Water Sys em Permit current? Yes No <br /> Does existing or proposed use make this a Public Water System ? F1 Yes No <br /> Is water/well sampling current? [:] Yes ❑ No <br /> Additional information or comments: <br /> 3. GARBAGE&REFUSE: <br /> Licensed scavenger pick-up? 1Y Yes E] No Service Area No. <br /> Other proposed disposal method: <br /> Potential Problem(s): <br /> 4. FLY MOSQUITO OR VECTOR CONTROL: <br /> Describe potential Vector Control issues: <br /> 5. TOILET/BATH FACILITIES: <br /> Number and Location(s)of existing facilities: <br /> Additional facilities required: <br /> 6. PREVIOUS OPERATION HISTORY: <br /> 7. GENERAL SANITATION: <br /> List any problem(s)not previously noted: <br /> 8. POPULATION DENSITY: <br /> Approximate number of people per square mile: <br /> EH 06 06 Report 47201 <br /> June 15,2005 <br />