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1 . EWA , bpd <br /> Distance to Public Sewers <br /> Does existing septic system comClnr1withoYjprdCe#549 Yes <br /> p y No <br /> Unknown If no, explain: Yes No <br /> Describe septic installation to be installed: <br /> 2 MATER �i1PAr `r' <br /> Is wat r�s PPlied by private Weil : <br /> Yes=No State def�ci� Yes No Is well <br /> ncy: proper: <br /> Does existing or porposed use make this well <br /> No ample of well water taken: YNs Public Water: Yes <br /> ResultsAdditional information or—comments Date taken_'_ <br /> 3 . i,. <br /> Licensed scaven er pick-up: Yes No Service Area No . <br /> Other proposed isposal method : <br /> Potential Problem: <br /> 4 . Mrn V ry } <br /> MHUAL <br /> State possible v�•c , r Potentiftl & necessary control ! <br /> 5 • Torr,rT/BTr <br /> No . & location exiUting. <br /> facilities needed –" Additional <br /> 6 • PRFVrnrls nPPRATT('�*� uT^m�-�RY <br /> 7 • S�aE�tERAI �APIT'1'A`)'TrIN <br /> State any Problems not previously otcd : <br /> 3 . FS�P[I ,ATTc'�N r,�;3SITV <br /> APPx. No . People per sq . mi . <br />