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1 . SWAGE ` <br /> Distance to Public Sewers 7'2°� 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: N� <br /> 2 . <br /> Is water supplied by private well : Yes Pio " Is well proper: <br /> Yee No State deficiency! <br /> Does existing or porposed use mare this well public water: Yes <br /> No. , - Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . , <br /> . Licensed scavenger pick-up: Yes No Service Area No <br /> E <br /> Otherproposed disposal method: <br /> Potential problem- <br /> QE ELL.1.M �Ii�_' �'PENTIAL <br /> State possibl vector potential necessar control ! <br /> 5 . TOILET/BATH FgGI TE2 <br /> fi No. & location existing: --- Additional <br /> facilities needed-- <br /> 6 . <br /> eeded$ . pBEYI_Gus OPERATION HISTM <br /> 7 . GENERAL S TA11111M <br /> State a problems neat previously noted-- <br /> S . c <br /> Appx. No. People per sq. mi . <br />