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t ' <br /> l• Connection necessarY: Yes No— <br /> 1 <br /> Dice to Public '72'Sewers ____. — <br /> Does existing septic system comply with Ord. ##548 : Yes x� <br /> Unknown— if no, explain: ` . <br /> Describe septic installation to -be installed: <br /> 2. WATER Sal PT. � ied b.r private well: Yes Na Is well proper: <br /> Is water supplied <br /> Yes,. No State defici..encY <br /> a 1 <br /> Does existing or porppBea 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 /> 'Licenced scavenger- k-UP' cies No Service Area No . <br /> Other -proposed disposal <br /> Potential problem: ' <br /> 4. ^, k'� '3TI� <br /> State possible vector potential 84 necessary control: <br /> 5 • TO + t' Additional <br /> No. & locution existing: <br /> facilities needed_--� <br /> s . ERE VI <br /> { <br /> 7 . <br /> State any problem--, not previously noted: <br /> Appx. Na . PeOPle per sq. mi . <br /> r. <br />