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i' <br /> 1 • SEWAGE ; <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> F Does existing septic .system comply with Ord. #549 : Yes No_ <br /> Unknown If no, explain: <br /> 4 <br /> 4 <br /> Describe septic installation to 'be installed: <br /> 2. WATER�SUPPLY <br /> Is water supplied. by private well : Yes iso Is well proper: <br /> Yes No State deficiency: <br /> r Does existing or porposed use make this well public grater: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . gAREAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . ELI. M QSOUZm QE V0 ZCi'[ENTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TQILETZBATH EAUILITE5 <br /> No. & location existing: Additional <br /> facilities needed _ <br /> 6 . PREYT0112 OkERA'i TON HIST(_£iY <br /> 7 . cENERn SAP#I, 'L'LQN- <br /> State any problems not previotialy noted : <br /> 3 . EC)PULAT-1014 DFc11,3ITY <br /> Appx. No. People por ..act. mi. <br />