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3 <br /> 1SHkIAGE <br /> • <br /> Distance to Public Sewers <br /> Connection necessary: Yes No <br /> Does existing septic system comply with Ord. 0549 : Yes No_ <br /> Unknown... If' no, explain: <br /> 6 ti <br /> Describe septic installation to •be installed: <br /> WATER SiTPPI,`I '' '" <br /> 2. <br /> Is water supplied- by private we 11: Yes No is well prover: <br /> Yes No State deficiency: <br /> Does existing or porposed use make this we Public water: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> s <br /> ResultAdditional information or comments <br /> 3 . <br /> Licensed scavenger pick-up: Yes Service Area No'. <br /> Other proposed disposal method: <br /> Potential problem : , <br /> 4. ELX 02 YEQ-TOR _POTENTIAL <br /> State possible vector potentiftl C necessary control: <br /> 5• TQILET/BATH FACfj,,•UE <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . PREUM15 QPFRATTQH HISTORY <br /> 7 . 1 T <br /> State any problems not previouel�ted-: _ <br /> 8 . jC)2EIjaATj0jJ _DEsYST" <br /> Appx. No. People per ..aq. r,i . <br />