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NOTE: PULL ALL PERMITS (Septic, Well, etc.) MAKE COPIES FOR FILE <br /> 1. SEWAGE: <br /> Distance to Public Sewers: Connection Necessary? ❑ Yes ❑ No <br /> Does Existing Septic System comply with San Joaquin County Development Title? ❑ Yes ❑ No D Unknown <br /> If no,explain: <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 ? E] Yes ❑ No <br /> Describe deficiency,if any: <br /> Is well system a Public Water system ? 0 Yes ❑ No Is Public Water System Permit current? ❑ Yes ❑ No <br /> Does existing or proposed use make this a Public Water System ? 0 Yes No <br /> Is water/well sampling current? ❑ Yes No <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE: <br /> Licensed scavenger pick-up? F-1 Yes F-1 No Service Area Na <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 11 Report 117201 August 01,2017 <br />