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1 . aF AG F <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . 0549 : Yes r No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> 2 . MATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes No �( State deficiency : <br /> ` ' <br /> Doe existing or porposed use make this well public water: Y <br /> No!W Sample of well water taken: Yes No Date tak <br /> Results Additional information or comments <br /> 3 . <br /> L ensed scavenger pick-up: Yes No Sery a Area No. <br /> Oth r proposed disposal method: <br /> Pote tial problem: <br /> 4 . FLY, Mn, QUITO ORvEoTaR 'zc NTI L <br /> State pos able vector potentifil & nece ary control : <br /> 5 . TOILET/BATH FACILITE:� <br /> No . & location existing,- Additional <br /> facilities needed <br /> 6 . PREVTOT72 OPERATION HIS'rnRY <br /> 7 . GENERAL SANTT <br /> State any probl y not previously noted : <br /> 8 . PQPULATTcW/DEtjSTjY <br /> Appx. /N People per sq. mi . <br /> 1- <br />