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1• SAGE Connection necessary: Yes No— <br /> Distance to Public Sewers - <br /> Does existing septic system comply with Ord. 41549 : Yes No— <br /> Unknown If no, explain: <br /> AWN Ir <br /> Describe septic installation to 'be installed: <br /> 2 . ITER SiTPpI,*I <br /> Is water supplied. b.a private well : Yes 10 Is well proper: <br /> Yes <br /> No State deficiency : <br /> Does existing or porposed use make tilis well public water: Yes <br /> No Sample of well water taken: Yes No Date taken,._______,,, <br /> Results Additional information or commentG <br /> J a <br /> .7 <br /> 3. GARBAGE & REFUSE r � <br /> Lice.need scavenger pick--up: Yes N ervice Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. Fla-. MnSAUITO OR V Q i'j`J:_N_TIAL <br /> State possible vector potential ?z necessary control: <br /> 5. TOILET/BATH FACiUTES <br /> No. ec location exieting: Additional <br /> facilities needed <br /> S . PREMIQU8 uERATIQu HISTQRX <br /> 7 . QENERAL SAPTI- `1'�4 'ION <br /> State any problems not previously noted: <br /> 8 . P-Q2111-ATION 12ENUTv <br /> Appx. No . People per .act. mi . <br /> 7- <br /> a-, <br />