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r <br /> F <br /> 1• <br /> Distance to Public Sewers Connection necessary: Yes No <br /> Does existing Beptic system comply with Ord. #549 : Yes No..,_, <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 2. WAJER 51JPPI-Y <br /> Is water supplied- by private well: Yes ilo Is well proper: <br /> Yes— No State deficiency: <br /> Does existing or porposed use make this well public crater: Yes <br /> No Sample of well water taken: Yes No Date taken_ <br /> Results Additional information or comments <br /> 3 . <br /> Licenced scavenger pick-up: Yes— No Service Area No._._� <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . OR POT , <br /> State possible vector potential & necessary control:_ <br /> k <br /> i <br /> 5. Q <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. BRRVTQUa OPERATIQLiO <br /> u K'Y <br /> r F <br /> 7 • GENERAL SAMITATIO-N. <br /> State any problems not previously noted: <br /> S . E_0pjj1.3Tjv <br /> Appx. No. People per sq. mi. <br /> F <br /> 4 <br /> J <br />