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i <br /> 7W / <br /> Distance- to Public Sewers Connection necessary: Yes No ✓ <br /> Does existing septic system comply with Ord. #549 : Yes No <br /> Unknown � If no, explain: <br /> Describe septic installation to 'be installed: <br /> 2 . <br /> Is water supplied. by private well : Yes ✓ 110 Is Well proper: <br /> Yes` No State deficiency: <br /> Doesisting or purposed use make tilis well public Water: Yes <br /> No - Sample of well Tater taken: Yea No Date taken <br /> Results Additional, information or comments <br /> 3 , E <br /> Licensed scavenger pick--up: Yes No - Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. ZLY.—MMOUT <br /> State possible vector potential % necessary control.: <br /> 5 . nr T Cr - ES <br /> No. & location existing: - Additional <br /> faci.li vies needed <br /> 6 . ?REVT0Ga-C,-P3RAjZMJ_-Hj3TQRY <br /> v� 5 (e <br /> 7 . G Ir IN F'..a- s1-ramT ON <br /> St�3ta :n;r Z-X ems nat pr eT:i ou I-. noted : <br /> No . ?e: 3t'= Z.,- 4 vC�cc� <br />