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1. SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No <br /> Does existing septic system comply with Ord. 4549: Yes No <br /> Describe septic installation to be installed: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes No Is well proper: Yes No <br /> State deficiency: <br /> Does existing or proposed use make this well public water: Yes No Sample of well <br /> water taken: Yes No Date taken Results <br /> 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 problems: <br /> 4. FLY. MOS UITO. OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5. TOILET/BATH FACILITIES <br /> No. & location existing: <br /> Additional facilities needed <br /> 6. PREVIOUS OPERATION HISTORY <br /> 7, GENERAL SANITATION <br /> State any problems not previously noted: <br /> 8. POPULATION DENSITY <br /> Appx. number of people per square mile <br />