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Distance to Public Sealers �.,� Connection necessary: Yes N <br /> Comely with Ord <br /> Does existing septic system 3 • Yes No— <br /> Does <br /> If no, explain: <br /> Describe septic installation to 'be installed-: <br /> 2. E-MIEPEU <br /> Is water supplied by private well: Yes �No Is well proper• <br /> Yes NoState deficiency <br /> Does existing or porPosed use make this weil public water: Yes <br /> No Sample of well Water taken. Yes No Date taken__ <br /> Results Additional information or comments_. l� <br /> GARBAGE3 . <br /> Licensed scavenger pick-up: Yes—. No Service Area No. <br /> Other proposed disposal methodt� <br /> Potential problem: <br /> 4. Ei,Y. toSQUITQ QR yT'^.T0R POTENTIAL <br /> State possib1e vector potential essary control: <br /> 5 . Q r ,rl <br /> No. & location existing: Additional <br /> facilities needed__-___ <br /> C <br /> 6. ERRYIQUS QPERATTON HISTOEX <br /> f r if <br /> 7 . rjENERAT, ,y T y t+p Tnay <br /> State any problems not previously noted: <br /> r <br /> S . n 7 T " <br /> Appx. No. People per sq. mi. <br /> 4 ,, <br />