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�4 <br /> i• <br /> Distance to Public Sewers Connection necessary: Yes �No_ _ <br /> Does existing septic syste comply with Ord. #549 : Yes No_, <br /> Unknown If no, explain: <br /> t <br /> Describe septic installation to 'be installed.-- <br /> 2. <br /> nstalled:Z. WATERSUPPI,Y <br /> Is water suppliedby private well: Yes Pio FIs well proper: <br /> Yes No State def iciency: <br /> Does existing or porposed use make this well public Water: Yes L� <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . aARBAG BEFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> State possible vector potential Fj necessary control: <br /> 5. TOILET/BATH F&aL ,iLTFS AJ44— <br /> No. <br /> & location existing . Additional <br /> facilities needed <br /> 6. E, C$MIQU Q RRATION HISTnEY. <br /> 7 . GENERAL SANTTA,TTQH <br /> State any problems not previously noted: <br /> $ . l -O NOT.= <br /> A x. No. People ea, s . mi. <br /> rp �� � <br />