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a <br /> 1,. SEWAGE ., <br /> Distance o .Publie Sewe s Connection necessary. Yes No— <br /> Does existing septic system comply with Ord. ##549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 2 . WATER SUPPLY / �+ <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 Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REEME <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . ELS R" ZCi[CNTIAL <br /> State possible vector potential necessary control: <br /> 5 . TQILET B/ ATH FAGILIi'ES <br /> No. & location existing : Additional <br /> facilities ' needed <br /> 6. PRFVT0(]9 OPERATION SORY <br /> i <br /> f % rVIP <br /> OF <br /> r y✓r <br /> 7 . GENERAL SAP�ITA`PTON <br /> State any problems not eviously noted: <br /> S . EOPULATTON DELISTTY <br /> Appx. No. People per ,sq. r,i . <br />