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1 . SFWA „ <br /> Distance to Public Sewers Connection necessary: Yes_ No <br /> Does existing septic system comply with Ord. #549 : Yeses No_ <br /> Unknown If no , explain: ' <br /> Describe septic installation to 'be ir;stalled: o ' °r <br /> / s s �i d c ,r <br /> 2. WATER SC1pPC,Y <br /> Is water supplied- by private wet es No— Is well proper: <br /> Yes No_ State deficiency: ° <br /> Does existing or porposed use make this well public water: Yes <br /> NoSample of well water taken: Yes_ No Date taken <br /> Re'sulta Additional information or comments <br /> G// v <br /> 3. GARRAGR & REFUSE <br /> Licensed scavenger pick-up: Yes,_ No� Service Area No. <br /> Other proposed disposal thod: 1��,I-�--z � <br /> Potential problem: <br /> 4. FiY M SAUTTO OR VECTOR POTENT?s <br /> State possible vector potential & necessary control: -2"9f <br /> 5 . TOItFT/BATH FACI .IL TES <br /> No. & location existing- <br /> facilities needed= 2rlr.Q� .Qes��Y""' �:�f��r o1L-Ed '2 <br /> Gr.,C�Ji✓l <br /> 6. PREVTOnS OPERATION HISTORY <br /> 7 . GrNJjgAT, SAtJTTA`1'TON <br /> State any problems riot Previously noted: <br /> 8 . PC)PTr ATTON I,EiiSTTv <br /> APPx • No . People per sq . mi . <br />