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Z y I <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . 0549 : Yes Nor_ <br /> Unknown If no, explain: ` - <br /> Describe septic installation to be installed: <br /> Z . WATER SUPPLE <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yeses No - State deficiency: <br /> Does isting or porposed use make this well public water: Yes <br /> ex <br /> No .��`�-�Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> w <br /> 3 . GARBAGE & REFUSE <br /> . Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method : <br /> Potential problem! <br /> 4 . ELY O� SQUI Q�--Y ,QT.QR PC}'MN "' <br /> State passible vector potential & 'necessary cont-xol: <br /> 5 . TOI LES''/BATH EAC I L 2. <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVIQUSOFERATION HISM <br /> 7 . r f +{AL 06NITAUM <br /> State any problems not previously noted : - <br /> 8 . <br /> oted : — <br /> Appx. No. People per sq. mi . <br />