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1 . SEWA aFP <br /> Distance to Public Sewers Connection necessary : Yes No_ <br /> Does existing septic system comply with Ord . #549 : Yes No_ <br /> Unknown jf no, explain: <br /> Us <br /> Describe septic installation to 'be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes io Is well proper: <br /> Yes No tate deficiency: <br /> � (" -P <br /> Does existing or porposed 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 disposal method: <br /> Potential problem: <br /> 4. =L MOSQUITO OR V ^.T() P.2M11T AJ.L <br /> State possible vector potentiftl necessary control: <br /> 5 . TOILET/BATH ICILITES <br /> No. & location existing : — Additional <br /> facilities needed _ <br /> 6 . PRFVTOf12 OPERATION HISTORY <br /> 7 . GENERAL SAPJIT '1,A ION <br /> State any problems not previously noted :- <br /> 8 . <br /> oted :_8 . POPULATION DrNSTTv <br /> Appx. No . People per Esq. mi . <br />