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1 . 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 /> De crib s tic installation to be installed: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well : Yes (— No_ Is well proper: <br /> Yes_ No_ State deficiency: <br /> /2 ' <br /> Does existing or porposed use make this well public water: Yes— <br /> No - Sample <br /> esNoSample of well water taken: Yes_ No�, Date taken <br /> Resul s Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes— No / 5ervice Area No. <br /> Other proposed disposal q,etho <br /> Potential problem- <br /> 4 . <br /> /�.ef ✓���� �� ���� �i�f� <br /> 4 . FLY, MOSQUITO OR VROTOR POT N_ TTAL <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: � Additional <br /> facilities needed <br /> 6. PREVIOUS OPERA//TION HISTORY <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted: <br /> 8 . POPULATION DENSTTY <br /> Appx, No . People per sq. <br />