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' a <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 /> 4 f <br /> " l <br /> 4 <br /> Describe septic installation to 'be installed: <br /> 2. WATER SUPPL'I <br /> Is War suppliedby private well : Yes No is well proper. <br /> Yes ✓ No State deficiency: <br /> Does ex ting or porposed use make this well public Water: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional .information or comments <br /> 9 . <br /> Licenced scavenger pick--up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. ELY, MOSQUTTQ_ORy R^ OR POTENTIAL <br /> State possible . vector potential & necessary control: <br /> 5• T—OILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVIOUS OPERATTQH HISIQRX <br /> rW <br /> 7. GENERAL 5AMITATION <br /> State any problems not previously noted: <br /> $ . <br /> PQ? <br /> S11,ATIOid I)RUSTTY <br /> Appx. No. People per eq. mi. <br />