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a <br /> SHWAaR r <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 /> inst <br /> led: <br /> Describe septic Inst tube - <br /> c2 0e, <br /> 2. UTFR SUPPLY ICK"`'`( <br /> Is Wate � <br /> supplied. by private well: Yes ZIio_ Is well groper: <br /> , <br /> YesNo State deficiency: <br /> Does existing or porposed use make this well publ-Ic Water: Yes <br /> NoSampl:e of well water taken: Yes No Dat taken <br /> Results Additional information or comments <br /> N � , <br /> 3 . <br /> Licenced scavenger pick-up: Yes No Service Area No.. <br /> Other proposed disposal method: <br /> Potential problem: <br /> r � <br /> 4 . ELI MOSbOITO OR VECTOR psi' 0TYAL <br /> State possible vector potential. & necessary control: <br /> 5 . OILET/BATH EACTLITES <br /> f No. & location existing: Additional <br /> facilities needed <br /> 6. EREZIQUS r, OHTSIORM <br /> - xd <br /> 7. <br /> State any problems not previously notsd: <br /> $ . pD BULATIQU DRMSITI' <br /> Appx. No. People per eq. Mi..�.. <br /> �` T 3 <br />