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1 . SEWAdE <br /> Distance to Public Sewers -0'4 Connection necessary: Yes No <br /> Does existing septic system comply with Ord. #549 : Yeses_ 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 Nom St,5,to def iciency : 42� J12911/ c.e✓ r�o..�fr1%c <br /> /e'.r� rEfl�c� �2od.✓d 4/l GG 9�D T•t'r¢9CG 4/.iCi�G Tl��!'d.(�.G,;s ��Gd� � <br /> � �;/.F,l� //.pyf�d�io ,�if� � .�oirG iir a ,.�°. ,,..< o �-✓'-r'E f,!�ir.'t,3O.' �„– f <br /> ri ..r/q�/9�� 9'/�i�a".lt <br /> �F J ! 4 i �r(` >�E ��9•rfE Cl P o ,D--r� �i`'/jF�i�°� <br /> Does ex� g ar porpos u e make t � s well public water: Yes <br /> No_ Sample of well water taken: Yes No )!�_ Date taken <br /> Results Additional information or comments o� <br /> 3 . GARBAGE & REFUSE <br /> . Licensed scavenger pick-up: Yes,,-,No /-- Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . ZWL. MOSQUITO OR y jaMMECi' ENTIAL <br /> State possible vector potential & necessary control: ���f <br /> 5 . TQILET/BATH FACILI7TS <br /> No. & location existing:- 41_� Additional <br /> facilities needed _ <br /> 6. PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANI'rA= <br /> State any problems not previously noted- <br /> 8 . POPULATIQN DENSITY <br /> Appx. No . People per sq. mi . b.�'�e�a,!•��.F'`z'" <br />