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I . SEWAGE <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 install d: 4 rcxlo <br /> i' <br /> 2 . NATER SUPPLY <br />} Is water supplied by private well : Yes NoIs well proper: <br /> Yes No State deficiency: _ <br /> Does existing or purposed 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 /> r <br /> t <br /> 3 . GARBAGE BEEUSE <br /> Li need scavenger pick-up: Yes No Service Area Na:' <br /> Othe proposed disposal method <br /> Pote=MIM-a-ac) <br /> : <br /> 4. ELYMNTAL <br /> State possible vector potential & necessarZ�ntrol : <br /> 5 . r <br /> No. & locatior, existing: _ Additional <br /> facilities needed <br /> 6 . PREVIOUS---Q=t ATIQN HISTD-IM <br /> 7.. QE,NERAL SANTTA'l TON <br /> State any probiAms not previously noted* <br /> S . POPUL MU 2 JOT-1 <br /> Appx. No. People per sq. mi . <br />