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1 . SRWAGr, <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 water supplied bar private well : Yes No_ Is well proper: <br /> Yes— No_ State deficiency: <br /> Does existing or porpoeed 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 /> 'v f h <br /> 3 . GARBAGE & REFOSfi W �1/ G� r.5 cj pkv' <br /> Licensed scavenger pick-up: Yes— No_ Service Area No. <br /> Other proposed disposal method: <br /> Potentlal problem:- <br /> 4 . FLY . MOSQUITO OR RQTQR POTENNTTAI_ <br /> State possible vector potential & necessary control : <br /> 5 . TOTLFT/BATff FACILIT ,a <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . PRRVTOOS r, s n <br /> 7 . GENERAL SANTTATTON <br /> State any problems not previously noted : <br /> 8 . P2PULAUQ)1 DF.2dSTTY �— <br /> Appx . No. People per sq. mi. <br /> 000 <br />