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4k e> <br /> l SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No <br /> Does ex.J,Jing septic system comply with Ord. 41549: Yes No <br /> Describe septic installation to be installed <br /> 2. WATER SUPPLY SO <br /> Is water supplied by private well: Yes No Is well proper: Yes No <br /> State deficiency: <br /> Does existing or proposed use make this well public water: Yes No Sample of well <br /> water taken: Yes No __VDate taken Results <br /> Additional information or comments: <br /> 3. GARBAG__,, & REFUSE <br /> Licensed scavenger pick-up: Y No Service Area No. <br /> Other proposed disposal method: <br /> Potential problems: <br /> 4. FLY, MOSQUITO, OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5. TOILETBATH FACILITIES <br /> No. & location existing: <br /> Additional facilities needed <br /> 6 PREVIOUS CIPERATION HISTO <br /> { Y <br /> 7 GENERAL SANITATION <br /> State any problems not previously noted: <br /> 8 POPULATION DENSITY <br /> Appx. number of people per square mi <br />