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w <br /> 1 . SEWAGE <br /> Distance to Public Sewers �r Connection necessary: Yes No <br /> Does existing septic system comply with Ord. #549 : Yes— No— <br /> Unknown— <br /> No_ <br /> Unknown If no, explain: <br /> Describe septic installation 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 existing or porposed use make this well pui>ic Water: Yes <br /> No Semple 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 proble ,: <br /> 4 . � M 0 S 0 U TO OR V ^,TC1 EL M1 <br /> State possible vect r potentirtl & ni-cessary control : <br /> 5 . TOI LET/BATH FACILITES <br /> No . & location, existing: 7 Additional <br /> facilities needed N _ <br /> 6 . PRFVIO(I, OPERATION HISTORY <br /> 0 <br /> 7 . QENERAL SAPJIT 'l,�i ION <br /> State any problem: not previously noted:_ <br /> 8 . POPULATION DENSITY <br /> Appx. No . People per rq. mi . <br />