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i <br /> 1. SHWAral <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existin4, Z,8jptic system comply with Ord. #549 : Yea No_ <br /> Unknown � explain: <br /> F <br /> Describe septic installation to 'be installed: <br /> 2. WATERU�,PPLY <br /> Is water supplied by private well : Yes ' No Is well proper.- <br /> Yes— <br /> roper:Yes bio State deficiencY: <br /> Does existing or porposed use make this well public Nater: Yes <br /> No— Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> S . UARBAGE <br /> Licenced scavenaer pick-up: Yes No Service Area No. <br /> f Other proposed disposal method: <br /> Potential problem: <br /> i 4. EITOR EC)rE :[TAL <br /> State possible vector potential. & necessary control: <br /> 5 . TnILET/BATH F&CYLIT r <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . EHEV I09 n ATInN RT----"' <br /> 7. GENERAL. SAILITA110 <br /> State- any problems not previously noted: <br /> a . POPULAITOIJ DUa-Ti ' <br /> Appx, No. People per .sq. mi. <br />