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1 . SAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . 41549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 2 . MATER SUPPLY <br /> Is water supplied by private well : Yes Pio 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 . =,­ MQSCrUITQ OR V ^,T() Z2r1A1IAL <br /> State- possible vector potentiftl & necessary control : <br /> 5 . TOTLET/BATH FACI ITES <br /> No . & location existing : — Additional <br /> facilities needed <br /> 6 . PREVTO05 OPERATION H <br /> 7 . GENERAL SAtJITATION <br /> State any problems riot previously noted: - <br /> 8 . <br /> oted: _8 . POPULATIO14 DEN STIR <br /> Appx . No . People per ren . mi . <br />