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MUM <br /> Distance to Fablic Sewers -,-- Connection necessary: Yes— No--_ <br /> Doea existing neptic system comply with Ord . 4549 : Yes--- No-- <br /> Unkncwn----- I! no, explain ,. <br /> Describe weptio irstallation to 'be installed: <br /> 2 <br /> is water Eupplied by 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— S.-imple of well water taken: Yes— No Date taken <br /> information or comments <br /> Licensed scavenger pick-up: Yes— No--- Service Area No. <br /> Other propoeed �.Ijqposaj, <br /> Potential problem <br /> jJTj A <br /> 4 . <br /> State possible vector potential & necessary control : <br /> No. & Additional <br /> facilities <br /> =a TLLIELFAWVoi01=2-Y <br /> 7 . <br /> State aa, P�nalosn cot prevtomaly noted: ------ <br /> Ayrxto , 000phe per M" ' <br />