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Distance to Public Sewers � Connection neceBsary: YeB No <br /> Does .existing septic system comply with Ord. #549 : Ye <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 1 <br /> 2. WATER SUPPLY Is <br /> Is water supplied. by private well : Yes � 't10Ie yell proper: <br /> Yes `J No State def 4ci;:ncyr •,� '�'`, ` "- r te' �'��C. � F <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water taken: Yes No�._Dmte taken-- <br /> Result's <br /> o n <br /> Resins A ditional information or commente ���'dd i� �� <br /> � 7 I <br /> 3 . <br /> Licensed scavenger pick-up: Yes No Service Area No <br /> Other proposed disposal method: <br /> Potential. problem: <br /> 4. pLy, EQSQUITQ Qg TC:Tf)R Poor UT_IAL <br /> State possible vector potential & necessary control: Z9La::& - <br /> 5 . O t" . <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVTOnS OpgRATTOU HISTORY <br /> 7 . GENERAL SANITAUM <br /> State <br /> • Stato s y problems not previously <br /> noted: <br /> f O s9 <br /> 3 . RopULAITON nEHSTTY <br /> Appx. No . People per sq. mi. <br /> 3 <br /> E <br />