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t.5 �4,74/ k <br /> 1 . SEWAGF <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: �. � l� <br /> Describe ee .inn. _be_.inst fled: <br /> 2. MATER SUPPLY <br /> Is water supplied by private well: Yes LN0 Is ce 1 proper: <br /> Yes No S e lcicncy: <br /> Does existing or porposed use make this well public crater: Yes <br /> No Sample of well water taken: Yea No Date taken <br /> Results Additional information or commentsf Al h o �' ✓v �T (� <br /> J <br /> C561 Koz;L., r <br /> 3 . GARBAGE & REFUSE �" rj ` '. �i , e.o s <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FIALLMOSQUIT0 ORVrf.TnR Mi'M <br /> State possible vector potentiftl & necessary control: <br /> 5 . TQTTLET/BATH FACTLITES <br /> No. & location existing: _ Additional <br /> facilities needed _ <br /> 6. PREVTOnS OP gATTON HTsTn <br /> a <br /> �! .,Q✓''� �� ,���t�,� �►.� S ��` �- lir � ' <br /> 7 . GENERAL SAIITTATION <br /> State any problems nat previously noted:_ <br /> 8 . ROPULATI O14 LirE `'T v <br /> Appx. No . People per req. mi. <br />