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1 . SEWAGEL <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__ae9_Ue- instal ation 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 eAisting or porposed use make this well public water: Yes <br /> No -,"Sample of well water taken: Yes Nom Late taken <br /> Results Additional information or comments k <br /> Z, <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes— No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY. MOSQUITO OR VECTOR_P0' ,NTIAL <br /> State possible vector potential & necessary control: <br /> 5 . TOTLET/BATH FACTL ITFS <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVTOnS OPERATION ; n <br /> 7 . GENERAL 1ITTAITON <br /> State any problems not previously noted: <br /> 8 . POPULATION DENSTTY <br /> Appx. No. People per eq. mi . <br /> i <br />