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1 . 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 /> 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 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 VZ21'TC1 Z2r <br /> State possible vector potentiftl & necessary control : <br /> 5 . TOILET/BATHrA_ CIL�ITES <br /> No. & location existing : _ Additional <br /> facilities needed _ <br /> 6 . PR .VTons c;PERATIOt_ ZHISTOF+Y <br /> 7 . GENERAL SANITATION <br /> State any problem: not previously noted :_ <br /> S . 20 ' 1 • Tloto DENSTTY <br /> Appx. No . People per req. mi . <br />