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1 . SAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic: system comply with Ord. 11549 : 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 iso Is well proper: <br /> Yes No State deficiency : <br /> Does existing or porposed use make this well public Water : Yes <br /> No Sample of wel:r water taken: Yes No Date taken <br /> Results______ Additional information or comments <br /> 3 . GARBAGE RCFUSF <br /> Licenced scavenger wick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLY. MOSQUITO OR VZ`'"O PuTrNTT r, <br /> State possible vector potential A-4 necessary control : <br /> 5 . TOTr,FT/ r,r`, <br /> No . & location exist,-ng: <br /> facilities needed_ Additional <br /> 6 . PRRVT0QS nprRAT ON H1•STn1tY <br /> 7 • (;FNERAI, SANTTATTON <br /> State any problems nct Previously noted: <br /> 3 . Pn 1 .ATZf3N V <br /> APpx. No. People per sq. mi . <br />