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1 . SAGE <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 /> 44 6 V41 <br /> . P <br /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY 2,17 15 <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes No State deficiency : <br /> Does existing or porposed use make tliis 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: 4,1_40 J'AAc. .. ai-rte <br /> 4 . L MOSQUITO OR Vr4TOR P,Si'j'J?N, TIAL <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PREVIOnE OPERATION HIST <br /> n � � <br /> 7 . GENERAL SAPlITA`1'ION <br /> State any problems not previously noted: <br /> 3 . pOPULATIOi4 Dr.NSIli _ <br /> Appx. No . People per cq. mi . <br />