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NOTE: PULL ALL PERMITS (SEPTIC, WELL, ETC...) MAKE COPIES FOR FILE <br /> 1. SEWAGE: <br /> Distance to Public Sewers: iv Connection necessary: Yes N <br /> Does existing septic system c mply with San Joaquin County Development <jitle ? <br /> Yes No Unknown If no, exp in: <br /> Describe septic installation to be installed: <br /> go 14 <br /> 2. WATER SUPPLY: <br /> Is water supplied by private well: Yes No Is well proper: Yes No <br /> State deficiency: <br /> jz <br /> Is well system a Public Water system? Yes No Is the permit current? Yes No <br /> Does existing or proposed use make this well Public Water: Yes No- (X Is water/well <br /> sampling current: yes No Additional informationr comments: <br /> 3. GARBAGE & REFUSE: / <br /> Licensed scavenger pick-up: Yes L1 No Service Area No.: Other proposed <br /> disposal method: <br /> Potential problem(s): <br /> 4. FLY, MOSQUITO OR VECTOR POTENTIAL: <br /> State possible vector potential and necessary control: <br /> 5. TOILETBATH FACILITIES: <br /> Number and locations existing: Additional <br /> facilities needed: <br /> 6. PREVIOUS OPERATION HISTORY: <br /> U <br /> 7. GENERAL SANITATION: 0/ <br /> State any problems not previously noted: ' eq <br /> 8. POPULATION DENSITY: <br /> Approximate number of people per square mile: Zf <br /> EH 06 06 Rev 1/99 <br />