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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 /> Describe septic installation to be installed: <br /> Z . WATER SUPPLY <br /> Is water supplied by private well : Yes No Ie well proper: <br /> Yes No State deficiency : <br /> Does existing or porposed 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 /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up : Yes No Service Area No . <br /> Other proposed disposal method: - <br /> Potential problem: <br /> 4 . FLY , MOSOUITO OR VTQTnPO' I;NTIAL <br /> State possible vector potential & necessary control: <br /> 5 . TOTLF.T/BATH F CTLITE <br /> No . & location existing: Additional <br /> facilities needed <br /> 6 . PRFVIQQS CPLRATION HISTnRY <br /> 7 . GENERAL SAN TATTON <br /> State any problems not­ previociW-ly noted : <br /> 3 . POPULATTOt4 DENSITY <br /> Appx. No . People per eq. mi . <br />