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r <br /> NOTE: PULL ALL EMITS (Septic, Well, etc.) MAKE SPIES FOR FILE <br /> 1, SEWAGE: <br /> Distance to Public Sewers: `m Connection Necessary ? ❑ Yes [3-'No <br /> Does Existing Septic System comply with San Joaquin County Development Title ? Yes ❑ No F Unknown <br /> If no,explain: <br /> Describe Septic System to be installed: <br /> 2. WATER SUPPLY: <br /> Is Water supplied by Private Well ? E5F-Yes F� No is well properly sealed and constructed ? E]-"6s ❑ No <br /> Describe deficiency,if any: <br /> Is well system a Public Water system ? Yes F1No Is lic Water System Permit current? Yes ❑ No <br /> Does existing or proposed use make this a Public Water System ? ❑ Yes Ej No <br /> Is water/well sampling current? F-] Yes No <br /> Additional information or comments: <br /> 3. GARBAGE&REFUSE: <br /> Licensed scavenger pick-up? Fa—A'es ❑ 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: <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 /> S. POPULATION DENSITY: <br /> Approximate number of people per square mile: , <br /> F 1106 06 Report 7201 March 30.2009 <br />