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1 . <br /> Distance to Public Sewers _� Connection necessary: Yes Nem. <br /> Does existing septic system comply with prd. 4549 : Yes; No <br /> UnknowIf no exp lain: <br /> Des r be eptic installation to 'be installed: ./��' �� � <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes "-,/ oIs well roper: <br /> Yes-4 No State def <br /> Does xisting or porposed use make this well public water: Yes <br /> NoSample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yeses No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem- <br /> 4 . <br /> roblem:4 . FLY . MOSQUITO OR MOTOR POTENTIAL <br /> State possible vector potential necessary control:. <br /> 5 . TO r_LET/BATH FAr.I LL TES <br /> No. & location existing. zj�i Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SAITTIA BION <br /> State any problems not previously noted: <br /> S . POPULATION DFHSTTY <br /> Apex. No. People per so . mi. q�✓�`��f /�flisllE�✓��.� <br />