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1 . SEWAGE <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 . WATER SUPPLY <br /> Is wateSr supplied by private well : Yes No_ Is well proper: <br /> Yes jjI 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 . UaF <br /> Licensed cavenger pick-up : Yes— No_ Service Area No . <br /> Other pro osed disposal method: <br /> Potential problem : <br /> 4 . FLY . MOSQU_IT\OR ECTOR POTUTIAL <br /> State possible vector potentihl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : _ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANTTATION <br /> State any problems not previously noted : <br /> 3 . P P 1 ,ATI iN DF2iSITv <br /> APpx . No . People per sq . mi . <br />