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1 . SKWAGE <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 SUPPLY <br /> Is water supplied by 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--.:L <br /> lesNo: Sample of well water taken: Yes_ No_ Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & RRF"USR <br /> Licensed scavenger pick-up: Yes✓ No_ Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: 1'� m\Q <br /> 4 . FLY , MOSQUTTO OR VRyTOR pOTENTTAI, <br /> State possible vector potential & necessary control : <br /> 5 . TOILETZBATH FACILITES <br /> No. & location existing : Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANTIATTON r <br /> State any problems not previously noted: <br /> 9 . POPULATION PUaTTY <br /> APpx . No. People per sq. mi. . <br />