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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord. $1549 : Yes ° No_ <br /> Unknown If no, explain: <br /> Describe septic installation <br /> /J to be installed: <br /> i%// r!>rj 1�1 "� A—- -- <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes ilo `� Is dell proper: <br /> Yes No State deficiency : a'� <br /> Does existing or porposed use make this well public water: Yes <br /> Na Semple 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 . Fes,- MOSQUITQ OR V 2' T—C Egr T <br /> State possible vector potentirtl ?z necessary control: <br /> 5 . TOI LET/BATH FACILITES <br /> No . & location existing: Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SAUI '1,A I— <br /> State any problem; not previously noted : <br /> 8 . F-O ' ILATION Dr iTl <br /> Appx. No . People per req . mi . L4 Ir 6j, � <br />