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i . SEWAGE <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 /> .i � dr ii fe <br /> Describe septic installation to 'be installed: <br /> 2 . WATER SUPPLY <br /> Is water s�ppliedby private well : Yes ZNo— Is well proper: <br /> Yes No � State def iciency: A-L I, L- 4c ! <br /> Does existing or porposed use make this well pubic water: Yes <br /> No ✓ Sample of well water taken: Yes No y Date taken <br /> Results - Additional information or comments <br /> 3 . GARBAGE & RRFUSr <br /> Licenced scavenger pick-up: `.'es No Servico Area No. <br /> Other proposed disposal method: ����� <br /> Potential problem: <br /> 4 . FLY , MOSOUTTn OF Vi;^TOR PO'rrNTIAL <br /> State possible vector potentiitl necessary control: <br /> 5 . TOILET/BATH FACT7,TTES <br /> . <br /> No. ek location existing: Additional <br /> facilities needed <br /> 6 . PRFVTons opTgATIoN HIsTnRY <br /> 7 , GENERA , 4AtTTTATTON ` <br /> State; wily problems not p2'ev' OU 1? noted : <br /> 3 . PPT_TLATION 7)r.ii:3T"T'Y <br /> Appx. No . Peopla per ac . mi . <br />