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h ' <br /> e ' <br /> 1 . S EWA GE <br /> Distance to Public Sewers *7aoV74 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 /> 2 . DATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yens No State deficiency: <br /> Does existing or purposed 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 di-- asa ethod: <br /> Potential proble <br /> 4 . FLY. MOSQUITO 0R 'J .(' (iR POT NTTAT, <br /> State po-ei-blf ,vector potential & necessary control- <br /> 5 . <br /> TOILET/BATH FAc:rr,T= <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERA , SAN TATI <br /> State any problem-- not previously noted : <br /> 3 . POPULATION DENSITY <br /> Appx. No . People per sq. mi . <br />