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4N <br /> Distance to Public Sewers Connection necessary: Yes No V <br /> Does existing septic syst comply with Ord. #549 : Yes No_ <br /> Unknown If no, explain: <br /> Deac i septic installation to 'be ins allel <br /> 2. ` <br /> Is wat supplied. by private wells Yes No Is well proper: <br /> Yeso State deficiency: <br /> Fwv to ate- <br /> Does existing or porposed use make this well public water: Yes—L <br /> No ` Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments _ <br /> 3 . <br /> Licenaed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposalethod: <br /> Potential problem: <br /> 4. 'r ENZIAL. <br /> State possible vector potentiftl & necessary control: <br /> 5 . MILETI�ATH 'EACTLITES <br /> No. ec location existing: Additional <br /> facilities needed <br /> 6. PREVIC}USITON H 1 1,;TDRI <br /> State any pr blew not previously noted: <br /> 8EQEULATTON n M - <br /> Appx. No. People per-eq'. rt. <br />