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NOTE: PULL ALL cRMITS (Septic, Well, etc.) MAKE OPIES FOR FILE <br /> 1. SEWAGE: <br /> Distance to Public Sewers: �f� Connection Necessary ? Yes [Er No <br /> /vl+ <br /> Does Existing Septic System comply with San Joaquin County Development Title? Yes No 0 u* n n <br /> If no,explain: <br /> Describe Septic System to be installed: <br /> 2. WATER SUPPLY: <br /> Is Water supplied by Private Well ? F_� Yes [2/ No Is well properly sealed and constructed ? Yes E:] No <br /> Describe deficiency, if any: <br /> Is well system a Public Water system ? F_� Yes Q No Is Public Water System Permit current ? Yes No <br /> Does existing or proposed use make this a Public Water System ? 0 Yes Q No <br /> Is water/well sampling current ? F—] Yes F-1 No <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE: <br /> Licensed scavenger pick-up? F—] Yes 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: 562:�- 3 <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 dzjL <br /> 8. POPULATION DENSITY: <br /> Approximate number of people per square mile: <br /> EH 06 06 Report H7201 Page 2 June 21,2004 <br />