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NOTE: PULL ALL EMITS (Septic, Well, etc.) MAKE COPIES FOR FILE <br /> 1. SEWAGE: <br /> Distance to Public Sewers: e-&)6 Connection Necessary? Yes No i <br /> Does Existing Septic System comply with San Joaquin County Development Title ? Yes ❑ No 0 U=n <br /> If no,explain: <br /> Describe Septic System to be installed: <br /> Z. WATER SUPPLY: <br /> Is Water supplied by Private Well? ❑ Yes Q No Is well properly sealed and constructed ? Yes ❑ No <br /> Describe deficiency,if any: <br /> Is well system a Public Water system ? ❑ Yes 0 No Is Public Water System Permit current? Yes F-1 No <br /> Does existing or proposed use make this a Public Water System ? F-1 Yes F-1 No <br /> Is water/well sampling current? ❑ Yes Ej No <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE: <br /> Licensed scavenger pick-up? Fv_j Yes ❑ 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 /> S. TOILET/ BATH FACILITIES: <br /> Number and Location(s) of existing facilities: 4 ( � <br /> Additional facilities required: <br /> 6. PREVIOUS OPERATION HISTORY: <br /> 7. GENERAL SANITATION: <br /> List any problem(s) not previously noted <br /> 8. POPULATION DENSITY: <br /> Approximate number of people per square mile: <br /> Ell 06 06 Btport 47201 Page 2 June 21,2004 <br />