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/VQ UGS� r <br /> 1 . SHWAGE <br /> Distance to Public Sewers Connection necessary: Yes No2(_ <br /> Does existing septic system comply with Ord. 31549 : Yes, , No_ <br /> Unknown If no, explain: 6190 <br /> Describe septic installation 1to 'be in tall d: <br /> U� <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well: Yes No Is well proper: <br /> Yes No State deficiency: 121Y Are <br /> 6�a g4 IZt Sum2 qa <br /> ,QcgvrG �vS`i` �1tiwti-7.c � �tG� �-• � o!u.`e-�'„-"5►. <br /> Does existing or porposed use make- this well public water: Yes <br /> Nos_ 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 . FLYS MOSQUITO OR V 2. Q pL)M T , <br /> State possible vector potential & necessary control : <br /> / l6 ;M w t.� &+ze- _ <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: _ Additional <br /> facilities needed <br /> 6 . PREVTOQS OPERATION HISTORY <br /> 7 . GENERAL SA1U! 'PION <br /> State any problems not previously noted- <br /> /ZU <br /> 8 . POPULATIQ14 DEL ST V N/,4 <br /> Appx. No . People per rel . mi . <br />