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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . 11549 : 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 � No Is well proper: <br /> Yes--&:�"No State deficiency : <br /> Does existing or porposed use make thin well public Water: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments Z &A A it <br /> ja <br /> 3 . GARBAGE & REFUSE <br /> Licenaed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . EI, MOSQUITQ QR V aT— ECi =AL <br /> State possible vector potentiFtl necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed _ <br /> 6 . PREVTOOR c; i RATIO <br /> JP1 OWN <br /> 7 . GENERAL SAIJIT �1_A 'ION <br /> State any problemz problemnot previously noted : <br /> 8 . POPULATION DENSITY <br /> Appx . No . People per sq . 1",i . <br />