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1 . fl../iWAGF i <br /> Distance to Public Sewers Connection necessary : Yes Nom <br /> Does existing septic system comply with Ord . #549 : Yes. _ No_. <br /> Unknown If no, explain : <br /> Describe septic installation t'o be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes >`No Is well proper: <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 /> Licenced scavenger pick-up : Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . ZLLyL MOS©UITO OR V ETC) EC)UNTIAL <br /> State possible vector potentiftl necessary control : j �l <br /> 5 . TOTLET/BATH FACUTT •S <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . pRFVTOlIS GPERATION HT-,,TDM <br /> 7 . GENERAL SAtUT '_A'ION <br /> State anis pro blemS not Previous ly noted: <br /> 3 . popULATION DENaST 1 <br /> A p p x . No . People per ren . mi <br />