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e --c�, '�I c tire' f <br /> 1 . SEWAGE � 7- y' l g r f d rD�� <br /> I � I <br /> Distance to Public Sewers /4D� Connection necessary : Yes Nc <br /> Does existing septic system comply with Ord . #549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed : <br /> (Q <br /> 2 . WATER SUPPLY ��� ��'� TS �✓� <br /> Is -supplied by private well : Yes No Is well proper: <br /> Yeswater __ State deficiency : <br /> Does existing or purposed use make this well public water: Yes <br /> No Sample of well water taken: Yes No Date taken <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 . FLY. MOSOUITL) OR J=, OR PQTENTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TQILET/BATH FACILI2Ta <br /> No . & location existi«g: Additional <br /> facilities needed -___ <br /> 6 . REVTOUS OPERATION_HI_,UC)RY <br /> 7 . GENERAL S�7ITA`I'ION. <br /> State any problems not previously noted: .__ _ <br /> 8 . POPULATIQN 12 : y1_ <br /> Appx . No . People per t3q. mi ._ <br />