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old <br /> 1 . SEWAGE <br /> �i.!�1C_r.'. <br /> Distance to Public Sewers Connection necessary: Yes No <br /> Does existing septic system comply with Ord. ix549 : Yes No— <br /> Unknown <br /> If /no, explain: <br /> Describe septic installation to 'be insta led:d <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes No State deficiency : <br /> Does existing or porposed use make this we'll 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 dispo , al method: <br /> Potential problem: « ier <br /> 4. L MOS. mss?JJQ QR v ,;:TO, PO rraLZIA <br /> State- possible vector potentiFtl necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . P.REVTOTI; OPERATION HISMEa <br /> n�btl05 <br /> �.�. }�Ql s� �v�f's � -k���r �•�- dam- u�-�.t. �� ��fs 5� ��'`='�:. <br /> 7 . GENERA 2A1U A`1'ION <br /> State any problems not previously note/d: — <br /> �8 d� /-/5 e k/5 c_.1 -'r7*'�J Wl <br /> 3 . POPULATIO14 DENSITY <br /> Appx. No . People per rq. mi . <br />