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o <br /> SKWAaH <br /> Distance to Public Sewers Connection necessary: Yes No— <br /> Does existing septic system comply with Ord. 0549 : Yes No— <br /> Unknown It no, explain: <br /> Describe septic installation to 'be installed: <br /> 2. WATER SUPPLY <br /> Is water supplied. by private well : Yes iso Is well proper: <br /> Yes No State deficiency: <br /> r I <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 & REEUSE <br /> Licenced scavenger pick-up: Yes No� Service Area No. <br /> Other proposed disposal method: <br /> Potential problem- <br /> 4. <br /> roblem:4. ELY, MQSdUITO QR VECTOR BOT ,NTIAL <br /> State possible vector potential & necessary control: <br /> 5. TOILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. EBE21QnZ QEERATInN HISJORY <br /> 7 . GENERAL 5A,MIATIQU <br /> State any problems not previously noted: <br /> 8 . PnPC3LAT.LQLi J2F�H 3 T T`•' <br /> Appx. No. People per sq . mi. <br />