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1 . SKWA.G <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . #549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 2 . SJATER SUPPLY <br /> Is Water supplied b,,j, private well : Yes No Is well proper: <br /> Yes No State deficiency : <br /> Does existing or porposed use make this well public Water: Yes <br /> No , Sample of wel- water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 � GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY. MOSQUTTO _OR r�:Tt?It POTCN TAI. <br /> State Possible vector potentiftl & necessary control: <br /> 5 . TOT FT/BATH FACTLITES <br /> No. & location existing: Additional <br /> facilities needed--- <br /> 6 . PRRVT-0- is OPLF.ATTON HIsTnav <br /> 7 . GENERAI= SANTTA' ION <br /> State any Problems not previously noted: <br /> 9 . POPULATION T)r` ST v <br /> Appx. No . People per aq. mi . <br />