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Distance to Public Sewers �'/r Connection necessarye <br /> Does existing ,. septic system comply w., th Ord. #549 : ' Y�a` Nom <br /> Unknowns_, If no, explain: Yes No_ <br /> Describe septic installation to 'be installed:_ 60 1 <br /> 2 . WATTE SUPpr,7 <br /> Is er supplied. by pri•.rate well : Yes K NO Is well <br /> Yes No State deficiency: Proper: <br /> Does existing or porposed use make this well public water: Yes_ ___ <br /> No ,Sample of well water taken: Yea Ido Date taken�� <br /> Reaults��, Additional, information or comments <br /> 3 . <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other Proposed disposal method: <br /> Potential problem: <br /> . OR pray : TT <br /> State possible vector Potential & necessary control: <br /> 5 . TOTLTT/13ATH FA <br /> No . & location existing: /t//91 <br /> facilities needed Additional <br /> ��' IVII/w4 <br /> 7. <br /> m � <br /> $t�1ty ani' problam8 not Pre'.-,Ou;l? noted: AWOVU <br /> � :{ . NO . i�;;'��3 Via: 3t; L.� / V •' <br />