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1. SRWAGK <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 2UPFU <br /> Is water supplied by private well : Yes iso Is well proper: <br /> Yee No State deficiency: <br /> Does existing or pornosed 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 pick-up: Yea No Service Area No. <br /> Other proposed disposal method:_ --• <br /> Potential problem- <br /> 4. FLY. MOSQUITn QR VV +^ nR PQ' <br /> State possible vector potentirtl eA necessary control: <br /> S . TQILETZB TH FACILZ' E3 <br /> No. & location existing: Additional <br /> facilities needed <br /> S. PRx3[T0gS OpER,AITON HISTnRY <br /> 7. GENERAL SANITATTQN <br /> State any problems not previously noted: <br /> S . POEUT-ATION DENS= <br /> APpx. No. People per [sq. mi. <br />