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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . 41549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> Z . WATER SUPPLY <br /> Is water sLt plied by private well : Yes No Is well proper: <br /> Yes No State deficiency : <br /> Does a sting or porposed use make this well public water: Yee <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information o'r^ comments <br /> 3 . GARBAGE & REFUSE <br /> Licenced scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem : <br /> 4 . =., M0S0UITO OR VE CTO 2 EC'fjjjjTIt1..1a <br /> State possible vector potentiftl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : _ Additional <br /> facilities needed _ <br /> 6 . PRFVT0Q5 OPERATION HISTORY- <br /> 7 . GENERAL SA14IT '1A ION <br /> State any problems not previoue;ly noted - <br /> 8 . <br /> oted :S . EC)PULATIQ14 DEt1STTY <br /> Appx . No . People Der ro . mi . <br />