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1 . BFklArM - <br /> Distance to Public Sewers . Connection necessary: Yes No_ h <br /> Does existing septic system comply with Ord. #549 : Yes No,_.,_ 1 <br /> Unknown If no, explain: <br /> ti <br /> Describe septic installation to 'be installed: <br /> Z. <br /> Is Water supplied by private well: Yes No Is well proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make this well public Water: Yes <br /> No - Sample of well water taken: Yes No bate taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Sr-rvice Area No._.,____ <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. ELL MOSOUTTr 08 mcTOR B01-12TTAL <br /> State possible' vector potential & necessary control: <br /> 5 . O r <br /> No. & location existing: Additional <br /> facilities needed <br /> S. PREYTOnS OPERATTON -HISTOILX <br /> 7. GENERAL SANTIATTON <br /> State any problems not preciously noted: <br /> S . BOPULAIIQH DEN TTv, <br /> Appy. No. People per .aq. ,i. �~ <br />