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71 <br /> R a <br /> i <br /> 1 . SEWAGE <br /> Distance to Public Sewers 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 SUPPL'I <br /> Is water supplied. by private well : Yes No Is well prover: <br /> Yes No State deficiency: - <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water taken, Yee No— Date taken <br /> Results Additional information or comments A &3-e ''r <br /> 3. GARBAGE & REFUSE � °`""� <br /> Licenced scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. �. rg TORFrtdTIAL <br /> State possible vector potential neceseary control: <br /> 5 . TQILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed _ <br /> 6 . PREYIOIT$ Qj!EHATI0N_HZ^TnRY <br /> y <br /> 7 . QENERAL SAP7I' TION <br /> State any problems not Previously noted : <br /> s , M)EULAM214 12ENallY. <br /> Appx. No. Peopl per .f3..q. M i. <br /> i <br />