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i . SEWAGE ; , <br /> Distance to Public Sewers - Connection necessary : Yes_ No x <br /> Does existing septic system comply with Ord. $1549 : Yes— No_ <br /> Unknown If no, explain : <br /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes ✓ tio_ Is well proper: <br /> Yee 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 . GARBAGE & REFUSE. <br /> Licensed scavenger pick-up: Yes= No_ Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: — j ,r <br /> 4 . FJ.,L, MOSQUITO OR Vr,,^_TT R-E 'ERNTTAL <br /> State possible vector potential PA necessary control : <br /> 5 . TOT ET/BATF{ FACILITES <br /> No. & location existing : Additional <br /> facilities needed <br /> 6 . PR .VT FFS O +.RATION HIST - RY <br /> 7 . GENERAL SAIJIT_ATION <br /> State any problems not previously noted : <br /> 8 . 1;0 1 ,ATIOIi DENSITY <br /> Appx. No . People per sq . mi . <br />