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d <br /> o �Gsrs- �� �,�a;, �✓ siva mss. <br /> 1 . SEWAGE <br /> Distance to Public Sewers 4�_ Connection necessary: Yew No <br /> Does existing septic system comply with Ord . 0549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Isw ter supplied by private well : Yes No Is well proper: <br /> Yes, No State deficiency : <br /> ml)'0i `, l ex't is Gfc A G..C.Yif gaei/e`tok .- `ZQS <br /> a� GrOSs 0141 cw 4n/7 2: :-,, 4vrrl /.f A,& wi a- l A o-� rG/rAs e i+/a <br /> Does existing or porposed use make this well public water: Yes <br /> Nom_ Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal. method: <br /> Potential problem: - <br /> 4. FLYS MOSQUITO OB VQTQL_PS'f Uj AL <br /> State possible vector potentiFtl & necessary control : <br /> 5 . TQILET/BATH FACTUTES <br /> No . & location existing: _ Additional <br /> facilities needed _ <br /> 6 . PREV_TOT7S OPERATION HISTORY <br /> 7 . GENERAL SANIT 'I.f M <br /> State any problems not previously noted : - <br /> 1 /4 <br /> 3 . POPULATIO14 DENSITY <br /> Appx. No . People per cq . mi . U/< <br />