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v ,J <br /> 1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . #549 : Yes Nb_ <br /> Unknown If no, explain: <br /> Describe septic installa ion to be installed : <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes No__ State deficiency : <br /> Does isting or porposed use make this well public water: Yes <br /> Nom_ Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . AGE & REFUSE <br /> Lic sed scavenger pick-up: Yes No Service Area Noy <br /> Othe proposed disposal method : <br /> Poten ial problem: <br /> 4 . =L MWBOUITO 0 1 POTNTIAL <br /> State pa Csible vector potentifil & necessary control : <br /> 5 . TQ LI_ET/B TLS H FAEIIUI- <br /> No . & location existi��g : — Additional <br /> facilities needed, <br /> 6 . PREVIOUS OPERON H.ISTLal <br /> 7 . GENERAL SATdITLII U <br /> Sta.te any pxr61-71ems not previousl.� noted : ---- <br /> / <br /> Lt�I�LEi�, 17 <br /> `px. No . People per sq . rn:i_ .___ <br />