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u W ,..: z 3 <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 /> 2. WATER SUP21-Y <br /> Is w supplied by private well: Yes -�i�o Is well proper: <br /> Yes No State deficiency <br /> Does existing or porposed use make this well public Nater: Yes <br /> No Sample of well water taken: Yea No Date taken <br /> Results Additional inform tion or comments <br /> 3 . GARBAGE & REEM <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. ELY, MQkQ110 OE 12Tc)R PCS MMIAL <br /> State possible vector potential gc necessary control: <br /> 5. nEACTUTES <br /> No. ec location existing: Additional <br /> facilities needed <br /> 6 . BREVIMIS OPERATIQU HISMU <br /> 7 . T <br /> State any problem~ not previously noted: <br /> 8 . M)PULATTO DEZE,TTv. <br /> Appx. No. People per oq. mi. <br />