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MWAU <br /> Distance to Public Sewers <br /> Does existing septic system complynwithonOrdce#548y. Yyes <br /> es <br /> No <br /> Unknown Ef no, explain: No— <br /> Describe septic installation to be .installed: <br /> k <br /> ----------- <br /> 2• �R SLrppr 4r <br /> Is water SUPPlied by Private well: Yes <br /> Yes No State deficie.nc : 140 Is -well Proper: <br /> -------------- <br /> Does existing or porposed use make t1lis Well Public <br /> No Sample of well water tarsen: Yes NoDa water: Yes <br /> Results----�� Additional information or comments <br /> te taken <br /> Licensed scavenger pick-UP: Yes No <br /> Other proposed disposal method: Service Area No. <br /> Potential problem: <br /> 4, FSO► ITTO nP ITRUOR EQUI,' TIAL <br /> State Possible vector potential & neceesary control : <br /> 5 . T_S? H <br /> No. & location existing:__"�____`T <br /> facilities needed Additional <br /> 6 . <br /> 7, <br /> State any problems riot previously rioted : <br /> Appx. No. People per sq. mi . <br />