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J <br /> 1 . SEWAGEi <br /> Distance to Public Sewers Connection necessary : Yes_ No <br /> Does existing septic system comply with Ord . 0549 : Yes_ No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: f✓/=�� <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes _ No Is well proper: <br /> Yes_ No_ State deficiency: eY <br /> Does existing or pox-posed use make- this we'll public water : Yes.,<— <br /> No Sample of well water -taken : Yes_ NoDate taken <br /> Results Additional information or commen s <br /> 3 . GARBAGE & REFUSE fir <br /> Licensed scavenger pick-up: Yes— No_ Service Area No . <br /> Other proposed dispos�J method : <br /> Potential problem:-4%:;< _ <br /> 4 . ELY MOSQUITO OR VK,TOR PO'rZ?RT1AL <br /> State possible vector potential & necessary control <br /> 5 . TOILET/BATH FACILITEa <br /> No . & location existing — Additional <br /> facilities needed_ <br /> 6 . PREVIOUS OPERATION gLiiTORY <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted: <br /> 8 . POPULATION DENSITY d / <br /> Appx. No . People per sq . mi . <br />