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1SRWAGR <br /> Distance to Public Sewers A)1, Connection necessary: Yes_ No ✓ <br /> Distance <br /> Does exist <br /> iAg septic system comply with Ord. 0549 : Yes_ No_ <br /> Unknown ✓ IE no, explain: <br /> �l ,®e✓ .�s <br /> 6n— 74 �fl� <br /> Describe septic installation to be installed: <br /> 1Va P a�- <br /> 2. WATER SUPPLY ��h� <br /> Is wa� supplied by private well : es ✓ No_ Is well prop <br /> Yes_ No_ State deficiency: <br /> Does ting or porposed use make this well pint water: Yes <br /> No Sample of well water taken: Yes_ No Date taken <br /> Results - Additional information or comments <br /> 3 . GARBAGE <br /> Licensed scaven r pick-up: Yes_ No Service Area No. <br /> Other proposed d poral method: <br /> Potential problem: <br /> 4. FLY. MOSoUIT0 ORym^ R Po,rRNTTAL <br /> State possible vector otentirtl necessary control: <br /> 5. TOILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PRXVTQnS r. <br /> 7. GENERAL SANT <br /> State any proble not previously noted: <br /> 9 . POPULATION DEbt-TTY <br /> Appx. No . Pe le per eq. mi. <br />