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NOTE: PULL ALOvkRINITS (Septic, Well, etc.) MAKE"+COPIES FOR FILE <br />1. SEWAGE: <br />Distance to Public Sewers: Connection Necessary' ❑ Yes E] No <br />Does Existing Septic System comply with San Joaquin County Development Title ? ❑ Yes ❑ No ❑ Unknown <br />If no, explain: <br />Describe Septic System to be installed: <br />Z. WATER SUPPLY: <br />Is Water supplied by Private Well? ❑ Yes ❑ No <br />Describe deficiency, if any: <br />is well properly sealed and constructed ? ❑ Yes ❑ No <br />Is well system a Public Water system ? ❑ Yes ❑ No Is Public Water System Permit current ': ❑ Yes No <br />Does existing or proposed use make this a Public Water System ? ❑ Yes ❑ No <br />is water / well sampling current ? ❑ Yes ❑ No <br />Additional information or comments: <br />3. GARBAGE & REFIJSE: <br />Licensed scavenger pick-up? F-� Yes <br />Other proposed disposal method: <br />Potential Peoblem(s): <br />❑ No Service Area -No.; <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 />I <br />E Additional facilities required: <br />1 <br />6. PREVIOtfS OPERATION HISTORY: <br />7. GENERAL SANITATION: <br />t <br />List any problem(s) not previously noted <br />8. POPULATION DENSITY: <br />Approximate number of people per square mile: <br />EH 06 06 Report 07201 Page i May 12, 2004 <br />