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r <br /> Distance ta,Public Sewers Connection necessary: yes No, <br /> Does exis ting septic system tem comply with Ord. #s549 : Ties No_ <br /> Unknown if no, explain: <br /> Describe septic installation to 'be installed: <br /> 2. ,WATER SRpPi.7 <br /> Is water supplied. by private well : Yes No Is Well proper: <br /> Yes No State deficiency: <br /> F <br /> Does existing or porposed 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 /> 3 . QARBaGg & RgEgEE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. 5 CTO ' :, TT <br />` State possible vector potential necessary control: <br /> i� <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVTOna OPERATTON HTSTORY <br /> t <br /> k <br /> 7. (37NERAT, SAN7TATTOM <br /> State any not noted : <br /> Per '3q. <br />