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1. MAGE <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 /> Z. 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: Yea No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY. MOSQUTTO OR VECTOR P0'f ,NTIAL <br /> State possibly: vector potentirtl & necessary control: <br /> 5. TOT , .T/ ATH FACILITES_ <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PRFVInf1,S_ OPERATION HISTORY <br /> 7 . GENERAL SAtTTATTON <br /> State any problems not previously noted: <br /> 3 . POPU .AT nN E HTTv <br /> Appx. No. People per sq. tai . <br />