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k <br /> 1• <br /> Distance to Public Sewers a onnection necessary: Yes No— <br /> Does existing septic system mply With Ord. #549 : Yea No— <br /> Unknown - If no, explain: e;r-� <br /> Describe septic installation to 'be installed: <br /> 2. WATER 5UPPLY <br /> Is Water supplied- by private well : 'Yes No Is Tie;l proper: <br /> Yes— No State deficiency: - -� <br /> Does existing or porposed use make this well public crater: Yes <br /> No Sampl6 of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . <br /> Licenced scavenge pick-up: Ye® No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY• IMEQULTQ..aR VECTOR <br /> State possible vector potential ?A necessary control: <br /> 5. TnILET/HATH EACILITFS <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVIORS OPRRATIn. N HISTORM <br /> 7. ra$NERAL SAITITATI <br /> State any problems not previously noted: 6 <br /> S . POPULATION DENSTTY <br /> Appx. No. People per eq. mi. <br />