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r <br /> Distance to Public Sewers �-fw 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 5[TPpL`r <br /> Is wat supplied- by private well : Yes iso Is well proper: <br /> Yes No Wncy: <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 /> Licensed scavenger pick-up: Yes— No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem- <br /> 4. <br /> roblem:4. ELY, k1Q5Q[IITO OR <br /> State possible vector pote al F& necessary control: <br /> 5 . TQTLE RATff FAC <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 PREYIOUS MHATION HISTORX <br /> 7 . GENERAL SAttITA:Z jQM- <br /> State any problems not previously noted: <br /> S . RO [P JLAT.s.I_T_DMUZZ <br /> Appx. No . People per sq. mi. <br />