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1, UWAG . <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existingseptic P system complywith Ord.. #549 • <br /> Yes <br /> 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 rake this well public hater: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other Proposed disposal method: <br /> Potential Problem: <br /> 4 . ELI, MOSQUIT-O .OR YEQTQR^PQ*rENTT AL a <br /> State Possible vector Potential & necessary control : � <br /> I <br /> I' <br /> 5 . n FACTUTES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . r] Q ON—HISTORY <br /> 7 . TIOIJ <br /> - . <br /> State any problems not previously rioted: , <br /> i' <br /> 8 . O ^T v ; <br /> Appx. No. People per f3q. mi .--- <br /> -�-- <br /> r <br />