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� 4 <br /> 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 SUPPLY <br /> Is water supplied by private well : Yes 10Ie well proper: <br /> Yes No State deficiency : <br /> Does existing or porposed use make this weil public Water: Yes <br /> No--Sample of well water taken., Yes NoJ,,--'bate taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REQ' 1SR <br /> Licenced scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem:__ <br /> 4 . ELY, M SQUTTO OR VV E^TOR PO'CENTTAL <br /> State possible vecte�r potentirti PA necessary con <br /> 5 . TOT .FT/BATH FACILTTFS <br /> No . & locution exist-trig ! Additional <br /> facilities needed,_. - <br /> S. PREV Tof7S (; kRAT (7.: K r,Tnnv <br /> _L <br /> 7 . GENERA , SANTTATTO <br /> State any problems not Previously noted: <br /> 3 POPU ,ATInri I)F'L4;TTv <br /> APpx . No . People per eq . ori <br />