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r <br /> 1 . SEWAGEi <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 /> k( KJ �o A CwdGr <br /> D7p'�c be s ptic installation to 'be ins alrlod: <br /> — �'I U I <br /> v <br /> vU <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes 1140�1 Is viell 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 & �ZEFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem,: <br /> 4 . =L MOSQUITQ OR V ^TCS P2T=AL <br /> State possible vector potentiitl & nez pessary control : <br /> 5 . TOILET/BATH EACILITE5 <br /> No . & location existing: _ Additional <br /> facilities needed _ <br /> 6 . PREVTnfis npERATioN HI cTOF(y <br /> 7 . GENERAL 5A1Jj r,ATJ-(-)N <br /> State any problem: not previously noted : <br /> 3 . pnpUL TIOIJ DF'Tv <br /> Appx. No . People per sq . vii . <br />