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�� \J <br /> 1• SEWAGF <br /> Distance to Public Sewers Connection necessary: Yes No— <br /> Does existing septic system comply with Ord. #548 : Yes No— <br /> Unknown If no, xplain: <br /> y <br /> Describe septic installation to 'be installed: <br /> 2. MATER S[TPPI,Y <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes No State gdeficiency: <br /> QWAT'7 <br /> /� <br /> Does existing or porposed use make this well public water: Yes ' <br /> No Sample of well water taken: Yes Pio Date taken <br /> Results Adqitional information or comments <br /> 3, <br /> Licenced scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. F.1, . M-Q5QUjjQ QB EQTQJ3 P�'MXjjAL <br /> State possible vector potential & necessary control: <br /> 5 . MILEUDATH "EACTLITES <br /> No. & location existing: Additional <br /> ..facilities- needed <br /> 6. PREVTOUS OPERATION HISTORY <br /> 7 . GENE13AL 56111TATIQ11 ` . <br /> State any problem~ not previously noted:__ <br /> 8 . MMULATTON Di t rr v <br /> Appx. No . People per .sq. mi . <br />