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1. AGE <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 SU PLY <br /> Is water supplied by private well : Yes 'No Is well proper: <br /> Yes No State deficiency: <br /> Does existing or porpoeed use make this well public water: Yes- <br /> No­ <br /> esNo­ Sample of well water taken- Yes No Date taken <br /> Results- Additional information or comments <br /> 3 . GARBAGR Et&F iS <br /> Licenced scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: - <br /> Potential problem:_., <br /> 4. FLY. MOSQUITQ ..QR YM TnR C)'rCN C1A ' <br /> State possible vector potentiitl +.c necessary control: <br /> 5. TQTTET/BATH laAC,ILITF.3 <br /> No. ec location existing, Additional <br /> facilities needed- <br /> 6 . EM OITS C' TION HTSTORY <br /> 7 . GENEEAt, ji7'CA' I(j)N <br /> State any problems not previouV 1y rioted: <br /> 8 . PPU ,A"1_ �l� r)r <br /> Appx . No. People per sq . m i . - -- <br />