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i <br /> 1 . SEWAGE <br /> Distance to Public Sewers LL Connection necessary: Yes No <br /> Does existing septic system comply with Ord . $1549 : Yes— No_, <br /> Unknown If no, explain: <br /> I <br /> Describe septic nstallation to 'be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yeses_ No Is well proper: <br /> Yes. No State deficiency: � - oy >© r <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water tarsen: 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 . =L_MOSQUITQ OR V E^TO PC)fjjjjTjA,14 <br /> State possible vector potentiftl & necessary control : _ <br /> 5 . TOTLET/BATH FACILITES <br /> No . & location existing : _ Additional <br /> facilities needed _ <br /> 6 . PREVI005 OPERATION HI STORY <br /> 7 . QENERAL SANTTATj_Q)N <br /> State any problems not previously noted- <br /> a . <br /> oted:8 . POPULATION hFi4nTTY � <br /> Appx. No . People per oq. r;,i.� ����TG�'��Ef�� <br />