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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes_ No_ <br /> Does existing septic system comply with 0 d. #549 : Yes_ No_ <br /> Unknown If no, exp1 in: <br /> Describe septic installation to be installed: <br /> 2 . WATERS SUPPLY <br /> Is water supplied by private well : Yes _ No_ Is well proper: <br /> Yes_ No_ State deficiency: p <br /> rDYI nr J� 16 CIO,-vh ill- �La�M � !iA(� f)VAL'r rr c� CA�? <br /> U <br /> Does existing or purposed use make this well public water: Yee <br /> No 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 pi-4:Zposed disposal method: <br /> Potential roblem: <br /> 4. ELY R VECTOR PO'rENTIAL <br /> State possible ector potential & necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing : _ Additional <br /> facilities needed <br /> 6. PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANITATION <br /> State any problems not previously note <br /> 8 . POPULATION D .NR TY <br /> Appx. No. People per sq. mi ._ <br /> t� <br />