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1 . SEWAGE <br /> t <br /> Distance to Public Sewers Connection necessary: Yes " No_ <br /> Does existing septic system comply with Ord . 0549 : Yes No_ <br /> Unknown If no, explain: <br /> Desc.ribe septic installation to 'be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes ado Is well proper: <br /> Yes No State deficiency : <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 . MOSQUITO OR V QTQ1 PS'f�A,'. <br /> State possible vector potentifil ?z necessary control : <br /> 5 . TQTLET/BATH FACILITES <br /> No . ec locution existing: Additional <br /> facilities needed _ <br /> 6 . PRFVTOt1S OPERATION HISTORY <br /> 7 . GENERAL SAijIT,}tiTjQN <br /> State any problems not previously noted : <br /> 3 . pnp[iLATION DFNSTIvL <br /> Appx. No. People per sq . mi . <br />