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1 . SEWAGE 16� 'P4 <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 vNo_ 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� i f rmation or comments <br /> 3 . GARBAGE & REFUSE (ti e 4 �� �� �•'' � U �'`�"� w <br /> fa <br /> Licensed scavenger pick-up : Yes_ No_ Service ArNo. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . MOSQUITO OR V Z;',TO E2 '•I <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: Additional <br /> facilities needed <br /> 6 . PREVToris O ATTgj H , <br /> a- <br /> 7 . GENERAL SANTTJ. TION <br /> State any problems list previou^ .rioted: <br /> s . F2E LATTON DENSITY <br /> Appx . No . People per sq, mi . <br />