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1 . SEWAGE �° <br /> Distance to Public Sewers i� ��Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . 0549 : Yes ✓ No--- <br /> Unknown---- <br /> o_Unknown no, explain: <br /> J ,�-�t 4 e0- C, ;5- <br /> Describe septic installation to 'be installed: <br /> 41 Olga�Ae <br /> 2 . MATER SUPPLY <br /> Is water supplied by private well : Yes —VL No Is well proper: <br /> Yes \ No State deficiency : <br /> Doexisting or porposed use make this well public water: Yes�AF— <br /> Noe Sample of well water taken: Yes No,�L Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE &',.REFUSE <br /> Licensed scavenger pick-up: Yes No�L Service Area No . <br /> Other propos6d disposal method, <br /> Potential problem: <br /> 4 . FAL MOSGQUITO OR VEQ10a m�i�ulA, <br /> State possible vector potenti4l & necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existirig: Additional <br /> facilities needed _ <br /> 6 . PREVIOU OPERATION HISTORY <br /> 7 . GENERAL SANTT '1,A 'IO <br /> State any problems not previously noted:-- <br /> 8 . <br /> oted:_3 . pnpuLATION DE±1a3TTy <br /> Appx. No . People per sq. mi . <br />