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1 SEWAGE <br /> Distance to Public Sewers _ Connection necessary Yes No <br /> Does existing septic system comply with Ord. 9549: Yes No <br /> Describe septic installation to be installed: <br /> 2 WATER SUPPLY <br /> Is water supplied by private well: Yes No Is well proper. Yes No <br /> State deficiency: <br /> Does existing or proposed use make this well public water: Yes No Sample of well <br /> water taken: Yes No Date taken Results <br /> Additional information or comments: <br /> �. <br /> GARBAGE & REFUSE <br /> Licensed scavenger pick-up Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problems: <br /> 4. FLY, MOSQUITO. OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> TOILET/BATH FACILITIES <br /> No. & location existing: <br /> Additional facilities needed <br /> 6 PREVIOUS OPERATION HISTORY <br /> 7. GENERAL SANITATION <br /> State any problems not previously noted: <br /> 8. POPULATION DENSITY <br /> Appx. number of people per square mile <br />