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I . SAGE <br /> Distance to Public Sewers L So 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 . WATER SUPPLY <br /> Is water supplied by private well : Yes coo ✓ Is well proper: <br /> Yes NoState deficiency <br /> A) <br /> <ws-H � <br /> Does xiatin or pdrposed use make this well public water: Yes <br /> No- e of well water taken: Yes No--'Date taken <br /> TA <br /> Results Additional information or comments <br /> 3 . GARBAGE: .,%REQ'USE <br /> Licensed scavenger pick-up: Yes No Service Ar a No . <br /> Other proposed disposal method: <br /> Potential problem:_ <br /> 4 . FLY, QSQUTTQ OP !.,-:TQR POTENITAL <br /> State possible vect potentiftl & necessa control: <br /> 5 . TQILET/BATH FACILITES <br /> No. & location exist — Additional <br /> facilities needed <br /> 6 . PREVIOUS 0 ERATIOU ; n <br /> 7 . GENERAL SANTTATT <br /> State any pro' ems not Previously noted: <br /> 3 . EQ12ULATT T) e, ,-T Tv, <br /> Appx. No . People per sq. mi . <br />