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1 . SEWAGE <br /> Distance to Public Sewers � Connection necessary: Yes No <br /> Does exist rig septic system comply with Ord. #549 : 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 fisting or porposed use make this well publ c water: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . 7th <br /> Li ensed scavenger pick-up: Yes No Service Area <br /> 0th proposed disposal method: <br /> Poter� ial problem- <br /> 'Y' <br /> L r OR yZ% PSS ,_TIAL <br /> State pos ble vector potential & necessary c Atrol : <br /> 5 . E rti <br /> No . & location exis lig : . Additional <br /> facilities needed- — -- <br /> 6 . PREVIOUS OPERATION HIST0 <br /> 7 . GENERAL .ANI"TAZLO-El. <br /> State any problems riot .,reviouslXned- <br /> 3 . _ <br /> Appx. No . Peop per sci. ml . - <br />