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NOTE: PULL ALL SITS (Septic, Well, etc.) MAKE CIES FOR FILE <br /> SEWAGE: <br /> Distance to Public Sewers: � CX Connection Necessary? ❑ Yes Q No <br /> Does Existing Septic System comply with San Joaquin County Development Title? ❑ Yes No Unknown <br /> If no,explain: <br /> Describe Septic System to be installed: <br /> WATER SUPPLY: <br /> Is Water supplied by Private Well? P;TYes ❑ No Is well properly sealed and constructed ?ten Yes F—] No <br /> Describe deficiency,if any: <br /> Is well system a Public Water system ? ❑ Yes 2: 'No Is Public Water System Permit current? Yes No <br /> Does existing or proposed use make this a Public Water System ? ❑ Yes No <br /> Is water/well sampling current? [:] Yes ❑ No <br /> Additional information or comments: <br /> GARBAGE &REFUSE: <br /> Licensed scavenger pick-up? EY-yes ❑ No Service Area No. <br /> Other proposed disposal method: <br /> Potential Problem(s): <br /> FLY,MOSQUITO OR VECTOR CONTROL: <br /> Describe potential Vector Control issues: f <br /> TOILET/BATH FACILITIES: <br /> Number and Location(s)of existing facilities: ,�,� �„r� _ <br /> Additional facilities required: <br /> PREVIOUS OPERATION HISTORY: <br /> GENERAL SANITATION: <br /> List any problem(s) not previously noted: <br /> POPULATION DENSITY: <br /> Approximate number of people per square mile: <br /> i <br /> 16 06 Report 47201 December 14,2009 <br /> i <br />