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L f <br /> SRkJAGR <br /> Distance to Public Sewers Connection necessary: Yes No_„_. <br /> Does existing septic system comply with Ord. #545 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> I <br /> 2. WATER SUT'PLY <br /> Is Water supplied. b;! 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 well water taken: Yes No Date taken <br /> Results Additional information or comments `z C? <br /> h <br /> 3 . ,E & REFUSE <br /> Licenced scavenger pick-up: Yea No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . ELY, MOSbUITO OR VECTOR EQ` <br /> State possible vector potential &—Meessary control: <br /> 5. TOILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVInns Gov TION HISTnRX <br /> 7. <br /> State any problems not previously noted: <br /> 3 . EOPULATIQN DENSTTY <br /> Appx. No. People per .sq. mi. <br />