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1 . SEWAGFF.. <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. EATER 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: Yes_ No_ Date taken <br /> Results Additional information or comments <br /> 3 . GARBA , . & REFUSE <br /> Licensed scavenger pick-up: Yes— No_ Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FAY MOSQUITO OR VECTOR P,O'j ;NTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : _ Additional <br /> facilities needed <br /> 6 . PR •VTOU,S OPERATION HIST <br /> 7 . GENERAL SANITATION_ <br /> State any problems not previously noted: <br /> S . POPULATION DENST-TY <br /> Appx. No . People per sq. mi . <br />