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1 . SAGS <br /> Distance to Public Sewers Connection necessary: Yes No_. <br /> Does existing septic system comply with Ord . #549 : Yes No— <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 2. WATER S[TPPI,Y <br /> Is water supplied 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 <br /> esNo _, Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGF & RdFE?SR <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem:_ <br /> 4. ELY, MOSQUITO–QR VrCTnR PQ'[ENTTAL <br /> State possible vector potentiftl & necessary control: <br /> 5 . TCIILFT/BATH FACT LITE. <br /> No. & locution existing : Additional <br /> facilities needed_. <br /> S. PREVI0f15 f%PCRATIO�'jfISTORY <br /> 7 . GENERAL SANTIA TOR <br /> State any problems not previously rioted: <br /> 8 . POPULATIQN D i,' ^T v <br /> Appx . No . People per sq. mi . <br />