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1 . SHWAGE b <br /> Distance to Public Sewers Connection necessary- Yes N�. <br /> Does existing septic system comply with Ord. 0545 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to *be installed:R ��cc _. <br /> 2. WATER SUPPLY <br /> Is water suppliedby private well: Yes .� NoIs well proper: <br /> Yes No .-State deficiency : , <br /> Does_ xistirig or porposed use make this well public water: Yes <br /> No Sample of well water 'taken:: Yes Na Date ,tak.en <br /> Resul s Additional information or commen s tel' <br /> 3. QARBAGE & REFUSE <br /> w Licensed scavenger pick-up: YesNo Service Area Nor m <br /> Other proposed .disposal method: <br /> Potential problem: <br /> 4. ELY -MQSQUjTQ. .QR _VECTQR PSTRMT.IAL <br /> State possible erector potential & necessary control: <br /> IN <br /> t 1'4J <br /> 5 . TOILFT/BATH FACI _,jTES <br /> No. y& location existing: ° ` Additional <br /> facilities needed _ <br /> S. RRFVI0175 OPERATION HIST012i <br /> _ 4M zim"'O'f '0�� <br /> 7-7 <br /> 7 . GENERAL SAINT 'E,A ION -/ <br /> State any problems not previously noted: <br /> Appx. No. People per- ..o.q.- M'. <br />