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SEWAQR 1 <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. WATER SUEEI-7 <br /> Is water supplied. by private well: Yes iso Is well proper: <br /> Yes No State deficiency : <br /> Does existing or porposed 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 . <br /> Licensed scavenger pick-up: Yes No Service Area- No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4• C�TC_R Po'rrNT2AI, <br /> State possible vector potentiitl necessary control: <br /> I <br /> 5 . QEACTLITES <br /> No. & locution existing: Additional <br /> facilities needed j <br /> 6. PREVIOUS QI!EHATToR HTslnnX <br /> 7. <br /> State any problems not previously noted: # <br /> I <br /> i <br /> S , Q i NST 1 <br /> APPx. No . People per Esq. mi. <br />