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1 . SEWAGE <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 /> Describe septic installation to be installed: <br /> 2 . MATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes No State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water tarsen: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. =.,- MOSQUITQ OR <br /> State possible vector potentiFtl necessary control : <br /> 5 . TQILET/BATH FACILITES <br /> No . & location existing: _ Additional <br /> facilities needed _ <br /> 6 . PREVTOMS OPERATrON HISTORY <br /> 7 . GENERAL SAj;TT,&TjQN <br /> State any pro'blem-s not previously noted: <br /> 8 . ROPULATIO14 DEtISTJY <br /> Appx . No . People per sq . mi . <br />