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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes No_ <br /> Does existing septic system comply with Ord . #549 : Yes No_ <br /> Unknown If no, explain : <br /> Describe septic installation to 'be installed: <br /> Z . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is yell proper: <br /> Yee 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 information or comments <br /> 3 , GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLY. MOSOUT10 QE V�Q.T02 POMMIAL <br /> State possible vector potential Pi necessary control: <br /> 5 . TO?LET/BATH FACILITES <br /> No. & location existing: ___ Additional <br /> facilities needed <br /> 6 . PEE VTOnS n ERATION HISTORY <br /> 7 . GENERAL SANTIATTON <br /> State any problems not previously noted : <br /> $ . p('►PtJT,ATInN DE;JSTTY <br /> Appx. No . People per act. mi. <br />