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1 <br /> 1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . 41549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private weld.: Yes .4- No Is viell proper: <br /> Yee' 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 /> - <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 . <br /> roblem:4 . FAL MOSQUITO OR V E^.TO ZCi'r ,NTIA j <br /> State possible vector potentiftl necessary control - <br /> 5 . <br /> ontrol :5 . TOILFT/BATH FACT ,TTES <br /> No . & location existing: �� Additional <br /> facilities needed <br /> 6 . PRFVIniTS npEpATTQN HTSTOFY <br /> 7 . GENERAL SA!U! '1,_A'_(_)U <br /> State any problems not previously noted: s -� <br /> 3 . PnPULATIOi4 DFLj,pITY <br /> Appx. No . People per cq. r,,i . <br />