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1 . SES <br /> Distance to Public Sewers Connection necessary : Yes Nom <br /> Does existing septic system comply with Ord . 0549 : Yes No— <br /> Unknown s_ If no, explain: <br /> De cr�ibe peptic installation to be installed: <br /> �c�.�lo�i 27�it •r <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well: Yes V No Is well proper: <br /> Yes No State Oficiency : d2-�6f <br /> <</�.0 �f a�f�c �c�c �� FGA �� z., F G ✓�'odc✓df hr ��c�� <br /> Does existing or porposed use make this welllic Water: Yes <br /> No 7` Sample of well water taken: Yes Nopu Date taken_T^ <br /> Results Additional information orgomments�e'�694i <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. MOSCjUITO QR V QTQ1 ZCi'EENTIA <br /> State passible/vector poten/tiftl & nece Bary control <br /> ,ee,�: - <br /> �/fi� i� ��/•r�G F<:%c e�•b iC7�/: (':. ef`-. GG�ff (e t/��.� , <br /> 6 . TOILET/BATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed- <br /> 6 . <br /> eeded6 . PREVIOQS OPERATION HI nTORY <br /> 7 . GENERAL SAtIIT `l ON <br /> State any problems not Previously noted : <br /> S . POPULATION DENSTIX . <br /> Appx. No . People per eq . mi.�����"��� <br />