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t - <br /> 1Diistan e to Public Sewers Connection necessary: Yes Noir .. <br /> Does existing septic system comply wi h Ord. #549 :N+ ,Yes No L, <br /> g <br /> Unnown if no, -explain: <br /> tic installation to 'be installed: <br /> Describe septic , <br /> 2 . WATER- SUPELY <br /> Is water supplied. by private well : Yes 2 _ No Is well proper: <br /> Yes. No State deficiency <br /> Does existing or porposed use make this well public water: Yes <br /> Nom' Sample of well water taken- Yes No-,Y.— Date taken <br /> Results Additional information or comments <br /> 3 . <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method.- <br /> Potential <br /> ethod:Potential problem: <br /> 4. SbUI TQ Q13 Y +"Tn ECI M UL. <br /> State possible vector potential PA necessary control: <br /> 5. FACILITES <br /> 1 <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 , Q , nN Hl-.,-TQRX k <br /> E _ <br /> 7 . A.Q <br /> State any problems not previously noted: <br /> 9 . prPILATION DFM51TAX <br /> Appx. No. People per 'f3q. r,i. <br /> ' a <br /> E } <br /> k <br />