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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes_ No= <br /> Does existing Eeptic system comply with Ord . $1549 : Yes_ No_ <br /> Unknown If ro, explain : <br /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY <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 . =t MOSQUITO OR _yEQTC)R PSTP.ETI9u <br /> State possible tiector potential & necessary control : <br /> 5 . TOILET/BATH FACI ITES <br /> No . & location existing : _ Additional <br /> facilities needed <br /> 6 . PREVIOUS O +RATIDii HISTORY <br /> 7 . GENERAL ^ IT '1A J.M <br /> State any problems not previously noted : <br /> 3 . POPUT,ATTON Ft4,;IT" <br /> Appx . No . People I>er sq . mi . <br />