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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 . WATER SUPPLYIs <br /> Is water supplied by t:-rivate well : Yes No Is well proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make tliis well public water : Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARB CUE <br /> r pi <br /> Licensed scavengeck-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: ---- <br /> 4 . <br /> roblem: —_--4 . ELI.,- MOSE�U�F�_Y 'n QE_PS)T NIIAL <br /> State possible vector Potential & necessary control : <br /> � r <br /> 5 . �f7Tj�ET/ ATH gAC'7t T'LF,� Additional <br /> No . & location existing : <br /> facilities need,e�d,•, u — <br /> 6 . PRFVTnttS C;PL� —+ °Zrl) <br /> 7 . . <br /> State any problems not previously noted: --- <br /> S , pr�t-�itt,ATIt�T���T� <br /> AvPX. No. People per X3-4 - <br />