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1 • SE11AGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . ##543 : Yes No— <br /> Unknown If no, explain : <br /> Describe septic installation to 'be installed: <br /> 2 . MATER SITPPI,Y <br /> Is water supplied by private well : Yes 'No Is well proper: <br /> Yes Na State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water taken! Yes No Date taken <br /> Results Additional in ormation or comments <br /> 3 . GAIMAGE & REFUSE <br /> Licensed scavenger pick-up: Yes Na Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. ELY -KOSOUTTQ OR VECTOR PO' IMAL <br /> State possible vector potential ex necessary control: <br /> 5 . TQILETIBATH FAa_IL1 E <br /> No . & location exio ting: Additional <br /> facilities needed _ <br /> S. PREVTQnS f;PCRATn HILTQa <br /> 7 . GENERAL SAJUJA'i'LC <br /> State any problems not pr evl.oLzwly noted : <br /> 9 EDEMA- 01 t�S T_a <br /> Apex. No . People per aq . mi . <br />