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is <br /> 1 . SHWArag <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 S[1PPL`I <br /> Is Nate supplied- by private well: Yes ✓ No Is well proper: <br /> Yes No State deficiency: <br /> Does ex ing or porposed use make this well public Water: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Res is Additional information or comments <br /> 3 . GARBAGE & REFUEE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method.: <br /> Potential problem: <br /> 4 . FLY, MOSQUITO nR V E^TO P. it[ENT.IAL <br /> Stage possible vector potentietl 4.c necessary control : <br /> 5 . TQILFT/BATH FACTLITES <br /> Na. & location existing: Additional <br /> facilities needed _ <br /> 6 . PRRYjQQ2 GPERATION HISTQRY <br /> r 4 ✓c-' <br /> w <br /> 7 . CE-NERAL SAPTFTA' jQjJ <br /> State any problems not previously noted: <br /> 8 . RQUILATIOtd PENS v <br /> Appx. No. People per sq. mi .-- <br />