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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes_ No,:— <br /> Does <br /> o=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 by private well : Yes No_ Is well proper: <br /> Yes Flo_ State deficiency : <br /> Does e�Yst.ing or porposed use make this well public water: Yes <br /> No ✓� Sample of we!'. water taken: Yes_ No_ Date taken <br /> Results Additional information or comments <br /> 3 . SARBAQR & REFUSR <br /> Licensed scavenger pick-up: Yes-- No_ Service Area No. <br /> Other proposed disposal method: <br /> Potential problem:- <br /> 4 . FLY. MOSQUITf9 OR Vin. R POTENTIAL <br /> State possible vector potential & necessary control: <br /> /)fit <br /> 5 . TnILF.T/BATA FACTUTES <br /> No . & location existing: Additional <br /> facilities needed _ <br /> 6. PRRyToaB (:PRRATIr1n. HjzTORY <br /> C ; 1 ,; <br /> 7 . GENERAL SMITTATTON <br /> State any problems not previou-sly rioted : <br /> 8 . P P 1 .AT Oto DEZ4STTY <br /> Appx . No. People per aq . mi. <br />