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1 . S3 E W A t' <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 /> 2 . WATER SUPPLY ✓� <br /> Is water supplied by pxjyajte well : `les No Is well roper: <br /> Yes No,— <br /> State deficiency: 7 • <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water taken: `lesNoDate taken <br /> Result: Additional information or comments <br /> 3 . GARBAGE & REFUSE � Cte" Gee► <.�► .,,, ,�� <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Omer proposed disposal method: <br /> Potential problem : ✓y.r �,L r +�r►' ,, -- : a. r Cr-/ c ir( <br /> 4 . FLY , MOSQUITO OR VECTOR POTENTIAL <br /> State Possible vector potential & necessary control: <br /> 5 . TLULET/BATH FACIr,IT� <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PREVIQU --QF <br /> ERATTOtd HISTORY <br /> .,- <br /> f <br /> 7 . GENERAL SANITATION <br /> State any problems not previously rioted : <br /> 8 . Ol )LA 21 UENSTTY <br /> Appx. No . People per sq . mi . <br />