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1 . SEWAGF, <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord , 11549 : Yea No_ <br /> Unknown If no , explain : <br /> Describe septic installation to 'be installed: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yee No State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water taken: Yee No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger p:.ck-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem:- <br /> 4. <br /> roblem:4. FLY, MOSQUTTO oR V CT a_PC)TTNTT <br /> State possible vector. potential & necessary control: <br /> 5 . TOILET/BATH FACTLLjTTE5 <br /> No. & location existirg: Additional <br /> facilities needed _ <br /> 6 . PREVTOnS GPERATTON HJ JQRY <br /> 7 . GENERAL SANTIA rTON <br /> State any problems not previously noted: <br /> 3 . POPULATION LEEN STTy <br /> Apps. No. People per ca . mi . <br />