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t <br /> 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 /> z. <br /> HAF-R9=UPPU <br /> Is Nater pplied. by private well: Yes <40— is well proper: <br /> Yes o S cy: <br /> DW ►,'' t -S �" 5 <br /> Does existing or porposed use make this Oell public water: -*es. -� <br /> No Sample of well water taken: Yes too Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REEQ5E <br /> Licensed scavenger pick-up..-Yes— No Service Area No. <br /> Other proposed disposal hod: <br /> Potential Problem: <br /> 4. �,, E TOR POTENTIAL <br /> State possible vector potentiftl gc necessary control : <br /> i <br /> x a <br /> 5 . 1QTLET/BATH ' FACILITE5- <br /> No. €i location existing: Additional <br /> facilities needed <br /> 6 . PREVTQTIS OPERATION HISTORY <br /> 7 . GENERAL SAUYTATION <br /> State any problems not previously <br /> ri t <br /> A eople per _an. mi. <br /> 5 ✓ �,� � �-'- J'--/�.o �".�-,�..o � �"� ;`�, .tea � �-,y,����'�''S'��J���.�. <br /> �- <br />