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NOTE: PULL ALL., , `RMITS (Septic, Well, etc.) MAKE PIES FOR FILE <br /> 1. SEWAGE: <br /> Distance to Public Sewers:_ .�/� Connection Necessary ? F—] Yes [No <br /> Does Existing Septic System comply with San Joaquin County Development Title ? Yes ❑ No F-1 Unknown <br /> If no,explain: <br /> Describe Septic System to be installed: <br /> 2. WATER SUPPLY: <br /> Is Water supplied by Private Well ? ,l Yes ❑ No Is well properly sealed and constructed ? F,7 Yes ❑ No <br /> Describe deficiency,if any: <br /> Is well system a Public Water system ? ❑ Yes 7 No Is Public Water System Permit current ? F_j Yes No <br /> Does existing or proposed use make this a Public Water System ? F_� Yes No <br /> Is water/well sampling current ? 7 Yes F—] No <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE: <br /> Licensed scavenger pick-up? [:] Yes E2/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: A111* <br /> 5. TOILET/BATH FACILITIES: <br /> Number and Location(s)of existing facilities: <br /> Additional facilities required: <br /> 6. PREVIOUS OPERATION HISTORY: <br /> ,Ac-- <br /> 7. <br /> AG7. GENERAL SANITATION: <br /> List any problem(s) not previously noted <br /> 8. POPULATION DENSITY: <br /> Approximate number of people per square mile: C <br /> EH 06 06 Report#7201 Page 2 June 21,2004 <br />