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1 . SRWAGE <br /> E <br /> Distance to Public Sewers Connection necessary : Yes_ No_ <br /> Does existing septic system comply with Ord . $1549 : Yes_ No_ <br /> Unknown IE no, explain: <br /> Describe septic installation to be installed: <br /> 2 . WATER <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 Sample of well water taken: Yes_ No_ Date taken <br /> Results Additional information or comments <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 . MOSQUITO OR VFX^,TOR POTENTTAL <br /> State possible vector potential & necessary control: <br /> 5 . TO . .T/BATA FAC TES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SAJITTATTON <br /> State any problems not previously noted : <br /> 3 . POPULATIQH DENSTTY <br /> Appx. No . People per eq. mi. <br />