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A <br /> 1. SRWAPal <br /> Distance to Public Sewers _ � Connection necessary: Yes Nod <br /> Does existing septic system comply with Ord. #549 : Yesz No— <br /> Unknown_ If no, explain: <br /> Describe septic installation to 'be installed: �' � <br /> i <br /> I <br /> . WATER SUPPLY <br /> Is writer supplied- by private well: Yes � zoo Is crell proper: <br /> YesNo State deficiency: ��L <br /> Does existing or porposed use make t}tis well public dater: Yes <br /> No ' V Sample of well water taken: Yes No.� Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE. & REFUSE <br /> Licensed scavenger pick-up: Yeses No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. ECTOR PO'r5NTTAL <br /> State possible vector potential 9z necessary control• ' <br /> 5. n r <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVTOOS r, n <br /> r <br /> C� <br /> 7. GENERAL SAUTTAIJON, <br /> State any problems not previously noted: <br /> 3 . EnPCIL TA TQj4 T)E 1SITV r <br /> Appx. No . People per eq. mi..��/�i/�� <br />