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Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . 19549 : Yes No— <br /> Unknown If no, explain : <br /> Describe septic installation to "be installed: <br /> 2 . WATER 59P,p Y <br /> Is water eupplied by private well : Yes no Is well proper: <br /> Yes Na State deficiency : <br /> Does existing or porposed use make tliis Stell public water: Yes <br /> No- Sample of well water taken: Yea No Date taken <br /> Results_ Additional information or comments <br /> Licenced scavenger pick--up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: - <br /> 4 . FLY , MOSQQ Tr 0R V �^ n pc,'r UTIAL <br /> State possible vector potentiFrl & necessary control: <br /> 5 . TOTLE'TZRATI L,-AQ=,a- <br /> No . & locution existing : Additional <br /> facilities needed_,.._ <br /> 6. EVTO(ISrpERA1j(-"t NLaz0I Y <br /> 7 . GENERAL• SAt=ATTQ) <br /> State any problems not previously noted: <br /> Appx . No . People rw r oci <br />