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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes_ No_ <br /> Does existing septic system comply with Ord . $1549 : Yes_ No_ <br /> Unknown If no, explain : <br /> Describe septic installation to be installed: <br /> or F <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes _ No_ Is well proper: <br /> Yes_ No_ State deficiency: <br /> Does existing or porposed use mace this well public water: Yes <br /> No Sample of well water taken: Yes_ No_ Date taken <br /> Results Additionalinformationor comments <br /> ' y { <br /> 3 . <br /> Licensed scavenger pick-up: Yes_ No_ Service Area No . <br /> Other proposed disposal method: <br /> Potential problem : <br /> 4 . $rty� MOSQUITO OR -yrQTOR POMtTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH EACT SITES <br /> No . & location existing : — Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION <br /> Hj;�jORY <br /> 7 . GENERAL SANITT}11'ION <br /> State any problem-. riot previously noted: - <br /> 8 . <br /> oted: _9 . POPU .AT ON DENSITY <br /> Appx. No . People per Bq . mi . <br />