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1, SEWAGE <br /> Distance to Public Sewers Connection <br /> Does existing BePtcsYgte�comply with Ord549Yee, , N <br /> Unknown If no, explain: <br /> Describe sept c install t n to 'be installed .- <br /> o � <br /> 2 . WATER SLTPPI,`I <br /> Is water Uuppli.ed. by private well: Yes No Is well proper: <br /> Yes No State def iciency: <br /> Does existing or porposed use matte this well ublic Nater: Yes <br /> No� Sample of well water taken: Yes No, Date <br /> Resu,_s Additional information or comments <br /> 3 . aARBAGE & REFUHE <br /> Licensed scavenger pick-up: Yes,4 No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY,..MOSQUITO 02 E IQR_Pff2NTIAi <br /> State possible vector potenti.ftl & necessary control,: o <br /> 5 . MILET/BATH FACILITES <br /> No. & location existing: ._ Additional <br /> facilities needed <br /> 6 . EREVTOUS OPERATION H11,;TO£Y <br /> 7 . ZAI]TTATIQU <br /> State any problems not previ.oualy noted: T <br /> 8 . }COPULATION DEN " v � <br /> Appx. No. People per scq . r,i. il'•`��� <br />