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� . SEWAGE , <br /> Distance to Public Sewers Connection necessary : Yes No_ <br /> Does existing septic system comply with Ord . 11549 : Yes 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 o Is well proper: <br /> Yeses State deficiency * <br /> Does existing or porPosed use make this well public Water: Yes <br /> No Sample of well water taken: Yes Neste taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licenaed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal me# rFid. <br /> Potential problem - <br /> 4. FLY.,_ MOSQUITO QR VECTOR �'r jNTIAL <br /> State possible vector potentiFtl & necessary control : <br /> 5 . TOILET/BATH FACIrIlTE'S <br /> No . & location existing: Additional <br /> facilities needed <br /> 6 . PRfE JVIOPS OPERATION HISTORY <br /> 7 . GENERAL SMUTAZL( <br /> State any problems not Prev`lous ly rioted : _ <br /> 3 . POPIJLATIO14 DEN S11y <br /> Appx . No . People per aQ. mi. <br />