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1. BEWAaR <br /> Distance to Public Sewers Connection necessary: Yes No— <br /> Does existing septic system comply with Ord. #549 : Yes No- <br /> 4 Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> t <br /> 2. WATER SUPPLYIs wa supplied by private well : Yes No Is well proper: <br /> Yes No S ,. <br /> Does ex ting or porposed use make this well public dater: Yes <br /> - <br /> No Sample of well water taken: Yes Nom Date to en <br /> Results— Additional information or comments ' - <br /> Licenced ac No <br /> pt er sed disposal method.-. ' <br /> Pot nti.Al pr m+r"''�"".. - <br /> 4. FLY. MOSOUTTO (78 VRICTOR POT A i d / <br /> State possible Vector potential & necessary control: QZ <br /> 5 . TOILET/BAT$„�FACIL,ITES <br /> No. & location exist Additional <br /> facilities needed <br /> 6. PREYT05 r :ERATIQtj HSSTORY <br /> c 1`c,.a� <br /> 7. GENERAL S6tdITAT7OM <br /> State any problems no' r-W otl no <br /> $ . J!Qj!ULATTQN DVLjSTTY <br /> Appx. No . People per sq. mi.. <br />