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Distance to Publid Sewers Connection necessary: Yes No— <br /> Does existing septic system comply with Ord. #549 : Yes No_ <br /> Unknown If no, explain: <br /> De <br /> ... - ,r <br /> 2. WATER SUPPLY <br /> Is Nater supplied. by private well : Yes No v __Is well proper: <br /> Yes_- No_ State deficiency : <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 . GA,F3BAG,F & RfiF`C1SE <br /> �f <br /> Licensed scavenger pick-up: Yes No Service Area- No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. n IT <br /> (State possible vector potential FA neces y control: <br /> 5. TOTLETIBATH Ci L'TES <br /> No. & location existing: �� Additional <br /> facilities needed <br /> 6. EREVIOn5 OPERATTOU HISIORX <br /> d G L <br /> 7. GENERAL SAHTTATION <br /> State any problems not Previously noted: <br /> 8 . P-..P_ULATION DERSM <br /> APpx. No. People per .sq. mi. <br /> 7,17— <br />