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i <br /> i. SRWAGK <br /> Distance to Public Sewers Connection necessary: Yes No— <br /> Does existing septic system comply with Ord. #548 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 2. HATER SLTPPLY <br /> Is Water supplied- byprivateWeil : Yes No Is well Proper: <br /> Yes_ No - State deficiency <br /> Does existing or porposed use make this well public Water: 'des <br /> No Sample of well water taken: Yes Na Date taken_ -- <br /> Results Additional information or comments <br /> 3 . GARBAGE. & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No._�___r__^_ <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4• EIMMO.SQUITQ <br /> try Qr 1 <br /> State possible vector potentifcl & necessary control: - <br /> 5 . O FACILTIES <br /> No. & locution existing: Additional <br /> facilities needed <br /> I <br /> 6. PRRVTQUS oPxR,&jTQM HISTM <br /> 5 <br /> 7 <br /> f State any problems not previously notzd: <br /> 9 . Sr " <br /> Appx. No. People per .aq. mi. <br />