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3 . SFWArZE <br /> Distance to Public Sewers Connection necessary: Yes No <br /> Does existing septic system comply with Ord. $1549 : Yes No_ <br /> Unknown If no, explain, <br /> Describe septic installation to be installed: . <br /> 2. WATER BURPLY b /I <br /> Is water supplied- by private well: Yes No�=Is well proper: <br /> Yee No State deficiency: <br /> i <br /> E <br /> w <br /> Does existing or porposed use rake this well public water: Yes <br /> No Sample of well water taken: Yes No 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 problem: <br /> 4. '"TQR P0T.r,,NTj <br /> State possible vector potentitel & necessary control- <br /> 5 . <br /> ontrol:5 . TQTj,FTZBATH { G. 1 n <br /> No . & location existing: Additional <br /> facilities needed <br /> $ , PREYTOTIS Q fi M <br /> a <br /> 7 . GENERAL SAP7IT,�J'SOli <br /> State any problems not previously noted:- <br /> 8 . <br /> oted:—V . BOPULAT1011 DE STIX <br /> Appx. No . People Per ,(3q'. mi . <br />