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1 . SEWAGE �y�,� <br /> Distance to Public Sewers .L _ Connection necessary: Yes No.,� <br /> Does existing septic system comply with Ord. tir-49 : Yes No <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: -�✓��� <br /> 2 . WATER SUPPLY <br /> Iser supplied by private well : Yes � No Is Drell proper: <br /> Yes t <br /> No State deficiency : <br /> Does existing or porposed use make this well public water: Yes ._ <br /> No Sample of well water tarsen: 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 . ZLLY _ MOSQU_ Tr, OR EQTQR P,Q'I'TajTjt , <br /> State- possible vector potential 8z necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : — Additional <br /> facilities needed _ <br /> 6 . PREVTOfIS O m O' C1F:Y <br /> 7 . QENERAL SANITATION � <br /> State any problems not Previously noted: <br /> 3 . POPULATION DENSTly <br /> Appx. No . People per r3c; . <br />