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1 . SEWAUE <br /> Distance to Public ,3e:wers Connection necessary : Yes No_ <br /> Does existing sept---c system comply with Ord . #549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied t--11 private well : Yes No Is well proper: <br /> Yes No State ceficiency : <br /> Does existing or porposed use make this well public water : Yes <br /> Na Sample of well water taken : Yes Na Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes__ Na Service Area No . <br /> Other proposed disposal method : — <br /> Potential problem: __ <br /> 4. FLY MOSQUITO OR VECME F-2L;NTIAL <br /> State passible vector potential & necessary control : <br /> 5 . TOILET[BATH FACILI7.'aa <br /> No . & location existing- Additional <br /> facilities needed_ <br /> 6 . PREVIOUS OPERATION 113-Mn <br /> 7 . GENERAL SANTT/91_'I0t- <br /> State an17 problems -.riot previously noted : - <br /> 8 . <br /> oted S . POPULATIQJ DE=a <br /> ADDx . No . PeoDle Per 6q . mi . _ -- - -- --- <br />