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I q <br /> f Distance to Public Sewers <br /> Connection necessary: ye$` No� <br /> Does existing septic syste comply with Ord. #549 : Yes <br /> Unknown_ If no, explairn� No <br /> Describe septic installation to 'be installed: <br /> I <br /> 2. NATER Snppr,v <br /> Is wr au lied. by priva <br /> pP l te well. Yes <br /> Yesat 110 Is well proper: <br /> No._.� State deficiency: <br /> Does existing or <br /> porposed use make this well public water: Yes <br /> No --" Sample of well Water taken: Yee No Date taken <br /> Results Additional information or comments <br /> 3 . <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem- <br /> 4. VFQTOR <br /> � <br /> State possible vector potenti,,tl u necessary control: <br /> 5. 10-TLET � <br /> No. & location existing: 1.b Additional <br /> facilities needed <br /> s. PREVTQUS n 0 <br /> EX <br /> 7. <br /> State any problems not previously noted: <br /> a . !2 ) S r v <br /> Appx. No. People per .aq. K-c rA- <br /> F <br />