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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes_ N04 <br /> Does existing septic system comply with Ord . $1549 : Yeses No_ <br /> Unknown If no, explain : / <br /> Describe septic installation to 'be installed: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes __-><, No_ Is well proper: <br /> Yeses No_ State deficiency : 7c� <br /> Does existing or porposed use make this well public water: Yes <br /> No — Sample of well water taken: Yes_ No_ Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUS . <br /> Licensed scavenger pick-up: Yes No_ Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLY , MOSQUITO OR VMOTOR PQ'Pj:,NTTAL <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: may' Additional <br /> facilities needed <br /> 6 . PREVTOUS O BRAT ON H STORY <br /> 7 . GENERAL SANTTATTON <br /> State any problems not previously noted : <br /> S . POPULATION DF.NSTTY � <br /> Appx . No . People per eq. mi . <br />