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t <br /> }. . BFWAG.L'L <br /> n <br /> Distance to Public Sewers system- o PlywithonOrdCe41549 : Yes No <br /> Does existing septic <br /> Unknown_ If no, explain: <br /> Describe se p is asta la inn to ''y installed:�� <br /> �9 f/�-� <br /> Z. WATER up]2I L <br /> Is wa er supplied. b:r Private well : Yes , Na Is cell Proper: <br /> Yes No State deficiency . d 2•Q� �o� �•� 1 _ :._,_..- <br /> 4 <br /> Does existing or porposed use make t1lis well public Water: Yes <br /> NoSample of well water taken: Yes ��o� Date taken <br /> Results Additional information or comments <br /> r <br /> l 3 . <br /> Licenced scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . EC)MNZzALL <br /> State possible vector potentittl & <br /> necessary control: -_ <br /> 5 . TQUET/13ATH ' FACILIMS <br /> No. & location existing. . Addition4l <br /> facilities needed <br /> 6 . EREYTQQaQT HjLnT_0_n <br /> 7 . f L SAPlTTr�A1IQH <br /> State any problems not previously noted: <br /> 8 . Appx. No. People per. ..rjq. mi . <br /> 1 <br /> l <br />