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NOTE: PULL ALL RMITS (Septic, Well, etc.) MAKE C CIES FOR FILE <br /> 1. SEWAGE: <br /> Distance to Public Sewers: ,Ufg Connection Necessary ? 0 Yes E]kNo <br /> Does Existing Septic System comply with San Joaquin County Development Title ? Yes No Ueew� <br /> If no,explain: <br /> Describe Septic System to be installed: <br /> 2. WATER SUPPLY: <br /> Is Water supplied by Private Well ? r-] Yes EZ/No Is well properly sealed and constructed ? Yes No <br /> Describe deficiency,if any: <br /> Is well system a Public Water system ? F-1 Yes F-1 No Is Public Water System Permit current ? Yes No <br /> Does existing or proposed use make this a Public Water System ? F-1 Yes I/ No <br /> Is water/well sampling current? F-1 Yes No <br /> Additional information or comments: <br /> 3. GARBAGE& REFUSE: <br /> Licensed scavenger pick-up? El Yes MNo 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: ///4 <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 /t//,4 <br /> 8. POPULATION DENSITY: <br /> Approximate number of people per square mile: �� - <br /> EH 06 06&eoort#7201 Page 2 June 21,2004 <br />