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(?) ` <br /> Distance to i'ublic Sewers %�'�/ Connection necessary: Yes N , <br /> Does exlaFing septic y — o <br /> p, eystea oowp y with Ord. X549: Xes No Unknown <br /> I! no, explain:•••". --- _ <br /> Uescribe septic installation to be installed: <br /> Additional inforwtion or comments: <br /> 2. WATER SUPFLY <br /> I0 water supplied by private well: Yes NO <br /> Is well proper: Yea No <br /> S,tr" deficiency: — <br /> Does existing or proposed use make this wel public water: Yes No <br /> Sample of well water taken:0. . Yes No Date Taken _ Results~ <br /> Additional information or comments: <br /> 3• LGE & RK: USE <br /> Licensed scavenger pivk-up: Yes _ N0 _✓Service Area No. <br /> Other proposed disposal method <br /> Potential problem: <br /> �• FLY. MOSQUITO OR VECTOR r0'TEriTLAL <br /> State possible vector potential & necessary control: <br /> S. AIF( f'OLLUTIG:: i'OT",ITlAI, <br /> ""e possio.e our�unD 07 N!'OCe , ,ln6 pul iu LanLs & necessary control : <br /> 6. MILET/BADi FACILITIES <br /> ho. & location existing: Additional facilities needed <br /> 7. ,iu'VIuu., ui .. ;TI01d IIIL�,P,I(y <br /> • GI:Ivh.ltA 1_ JAI,i;A TION <br /> SLaLo ajV problems nol ievly iu, .. ,i : <br /> 9. POPULATION DENSITY <br /> Appx, No. People per sq, mi . <br />