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1 . SEWAU L <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 <br /> �i,,�=p T p F Y . <br /> Is water supplied by private well : Yes Cao . Is well proper: <br /> Yes No State deficiency : <br /> Does existing or porposed use mare this well public water: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comment <br /> 3. GARBAGE & REFUSE <br /> . Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLY, MMQUIM QR Y QTQB M NTIAL <br /> State possible vector potential. & necessary control : <br /> 5 . TOILET/BATH £AaI1J_1,'ES <br /> No. & location existing: _ Additional <br /> facilities needed <br /> 6. RREY102 UERATIQU HISTORY <br /> 7 . GENERA ' ATION <br /> 'ION <br /> St.Ate any problems not previously noted! -- <br /> 8 . <br /> oted: .TM8 . POPULATION DENSITY <br /> Appx. No. People per sq. mi. ' <br /> ,1 <br />