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t 1 . SEWAGE <br /> f Distance to Public Sewers y2�� Connection necessary! YesV., 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. WATER -i1PPiLY /� <br /> Is water supplied try private well : Yes No �/ Is well proper: <br /> Yes No State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No__Z_ 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 /> Other proposed disposal method: <br /> Potenti. 1 problem: <br /> 4 . EKY� VECTOR PSj'U TIAL <br /> State Possibl''e vector potential & necessar control : <br /> No . & location existing; Additional <br /> facilities needed <br /> 6 • _ ^ X y <br /> 7 . QRNERAL S TTA"' 7 <br /> State ar problems not previously noted: — <br /> . 8 . <br /> oted: <br /> . S . T t <br /> Appx. No . Feople per sq. mi . <br />