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1 Connection necessary : Yes_ No— <br /> Distance to Public Sewers <br /> Does existing septic system comply with Ord , 0549 : Yes— No_ <br /> Unknown IE no, explain : <br /> Describe septic installation to be installed: <br /> 2 , WATER S[TPPL.'fIs well proper: <br /> Is water supplied by private well : Yes _ No_ <br /> Yes_ 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: <br /> 4 . FLY MOSQUITO OR V RCTOR ECiljIMA , <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH FACTLITF.S <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted: <br /> 9 . POPULATION DENSITY <br /> APPx. No . People per aq . mi . <br />