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i , SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No, <br /> Does existing septic system comply with Ord. #549 : Yes No— <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 2• WATER SUpPE.7 ` <br /> Is Water supplied. by private well : Yes 110Is well proper, <br /> Ye$ No State deficiency: <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARB v <br /> Licenced scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: . <br /> State Possible vector potential & necessary control: <br /> 5 . MILETZ136TH Iaal=d <br /> No. & location existing: Additional <br /> facilities needed <br /> 7 . <br /> State any problems not previously noted: <br /> 3 . n r 4* •-r v <br /> Appx. No. People peraq. mi._.�. � <br />