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1 . $SAG <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 /> Deso Rep is installation to 'be stalled: <br /> Li <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <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 Dat taken. <br /> taken <br /> Results Additional information or comments �` Z% 1 <br /> 3 . GARBAGE REFUSE <br /> Licenced scavenger pick-up: Yes- No Service Area No. <br /> Other proposed disposal met d: <br /> Potential problem:_ <br /> 4 . FLY, MOSQUITO OR yMQT0R POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5 . TQTLET/BATH I'ACILa <br /> No. & location existing: Additional <br /> facilities needed-m. <br /> 6 . PREVTOnS 0 HISTORY <br /> 7 . GENERAL= 5AN1jATIQjj <br /> State any problems not <br /> previous-1-noted: <br /> 9 . POEULATIQN DENSTTX <br /> Appx. No. People per sq. mi . <br /> 04 ��'-q <br />