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I . Distance to Public Sewers Connection necessary ! Yes No_ <br /> Does existing septic system comply with Ord. 0549 : Yes No— <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> 2 . <br /> Is water supplied by private well : Yes �_ No Is, well proper: <br /> No State def <br /> iciencY : <br /> Yes � <br /> Does existing or purposed 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 /> tY. <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> { Potential problem: <br /> 4. <br /> State possible vector potentialnecessary control - <br /> 5 . T. T/BATH EA�'� Additional <br /> No. & location existing : — <br /> facilities needed - <br /> 6 . PERVIOUS <br /> 7 , QENERAL <br /> S s r <br /> state any problems not previously noted: — <br /> 3 . P02ULAZDt IL-DEN= <br /> Appx. No . People per sq. mi . <br />