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1 . AGE <br /> Distance to Public Sewers Connection necessary: Yes­7 <br /> No_ <br /> Does existing septic system comply with Ord . #549 : Yes j' No_ <br /> Unknown If no, explain : <br /> Describe jaeptic ins allati n to 'be irpstalle : 42 <br /> r <br /> S <br /> 2 . WATER SUPPLY � W,k jj,l�,� fro be loCt�� <br /> Is water supplied by private well : Yes G No Is hell proper: <br /> Yes No State deficiency: <br /> �M�51 nn�vS & - <br /> Does existing or porposed use make this well public water: Yes- <br /> No -2- . <br /> esNo—_, Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 , GARBAGE & REFUSE <br /> Licenced scavenger pick-up: Yes Nod Service Area No. <br /> Other proposed disposal method: <br /> Potential problem:_ <br /> 4 . FLY. MOSnUTTO ,QOF yMQT0QR -P(-)'r ,NTTAT, <br /> State possible vector po-tentiril & necessary control: <br /> w� <br /> 5 . TOILET/BATH FACILITEa. <br /> No . ec location existing: Additional <br /> facilities needed <br /> 6 . PRRVIORS QPERATIcp:N MjSTnRy <br /> Z6LA C X)A gag <br /> V <br /> 7 . GENERAL SANIJAITOn <br /> State any problems not previou-sly noted: <br /> 3 . POEULAT nt4 r) j<, ^T v <br /> Appx. No. People per sq. mi. <br />