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1 . SERE <br /> Distance to Public Sewers — Connection necessary : Yes No_, <br /> Does existing septic system comply with Ord . #549 : Yes `c No_ <br /> Unknown If no, explain : �. <br /> Describe septic installation to be installed : <br /> ✓1 IA <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes No State deficiency : <br /> c. (.n C� Sec" Philc.� <br /> At` vutUL ►S (' rvss Cd-reeleA "0 4l # <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: <br /> 4 . FLXL MOSQUITO OR YECTOR �iTENTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANIMION <br /> State any problems not previously noted: _ <br /> S . POPULATION DENSITY <br /> Appx . No . People per sq . mi ._ <br />