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N <br /> 1, MWAGE <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 /> • f <br /> Describe septic installation to 'be installed: <br /> 2. WATER SUPPLY <br /> Is water supplied. by private well : Yes No Is well proper: i. <br /> Yes No State deficiency: <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of -well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> i <br /> 3 . GARBAGE & REFUSE <br /> Licenced scavenger pick--up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> i <br /> 4 . Er Y. MOSQUITO CSR Y •^ EQ)TENTIAL <br /> State possible vector potential & necessary control: <br /> 5 . Tf9 LET/BATH EACIIITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PRFYIQn r. TTOLJ HTSTORI <br /> 7 . QENERAL SAIITTAITON <br /> State any problems not previously noted: <br /> 8 . P„QEjJf.ATTntJ DENSIT:' <br /> App:t. No. People per .sq. mi . <br /> I <br />