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s <br /> 1 . SFWAaT' <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 well proper: <br /> Yes NoState def icieney : �f <br /> Do isting or porposed use make this we'll public water: Yes <br /> Noes x� Sample of well water taken: Yes No "-- Date to en <br /> Results Additional information or comments 7 � <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yeses No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . =,- MOSQUITO QB V21 T zC)rM1 1 <br /> State possible vector potentiftl & necessary control : <br /> 5 . TOTLET/BATH FACILE T '•S <br /> No. & location existing: �' Additional <br /> facilities needed <br /> 6 . PREVIOM OPERATION HISTO r <br /> .�id1F .rE.�o cg�af/ �1✓,1-o..�E✓✓e/��' i9,l�i�'d,C� �. �o�r Q4/�'f,� <br /> ��' .+�Jo61:Cf fyo�<'f /lam/O4E�' �F��✓.O �d/c�J v�� t�-CG��f, <br /> 7 . GENERAL SAtU'T,AITON <br /> State any problemz not previously noted: <br /> 8 . EOP li TION DE NSTIy.. <br /> A p p x . No . People per 6q . mi .� �C�� �� --PF✓i.�fC <br />