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1 . aE.EI6Sa.� <br /> Distance to Public Sewers Connection necessary : Yes No-- <br /> Does <br /> o_Does existing septic system comply with Ord . 0549 : Yes No-- <br /> Unknown---- <br /> o_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 Sample of well water taken : Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: _ <br /> 4 . FLY, MOSQUITO OR_YZIM—MUTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACILI115 <br /> No . & location existing : Additional <br /> facilities needed_____ _ <br /> 6 . PREVIOUS OPERATION H.IDORY <br /> 7 . GENERAL SAKI.. TT <br /> State any problems not previously noted : ._ <br /> 8 . POPULATIQN DEiJSITY <br /> ADDx . No . People Per sq . mi . <br />