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1 . .SEWAGE <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 /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes _ Noll Is well proper: <br /> Yes_ No_ Slate 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 VECTOR POTENTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> l rE C-- <br /> 7 . <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted: <br /> 8 . POPULATION DENSITY <br /> Appx . No . People per sq . mi . <br />