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1 . zEWAGF <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . 11549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> -tit rya 1 �'?�5 •, -�-' / , S <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: Yea No Date taken <br /> Results Additional information or comments (7X p -t •- f JT1 J�� <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . = MOSQUITO OR V ^.TO Elf M1 AL <br /> State possible vector potentiftl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : _ Additional <br /> facilities needed <br /> 6 . PREVTOQ5 CEERATION HISTORY <br /> �- '4 <br /> 7 . C +.NERA , SAIIIIATIOR <br /> State any problems not previously noted : _ <br /> 8 . POPULATION DE N3SIT-Y <br /> Appx. No . People per sq . mi . <br /> ? i 5U ew2 <br /> � osell <br />