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1 • SKWAGE <br /> Distance to Public Sewers Connection necessary : Yes— No, <br /> Does existing septic system comply with Ord . #549 : Yes— No_ <br /> Unknown Ii no, explain : <br /> Describe septic installation to be installed: <br /> 2 . DATER SUPPLY <br /> Is water supplied by private well : Yes _ No' Is well proper: <br /> Yes_ No_ State deficiency : <br /> Does existing or porposed use make this well public water: Yes— <br /> No —' Sample <br /> lesNoSample of wel`. water taken: Yes_ No_ Date taken <br /> Results Additional information or comments <br /> 3 . ��u. 4�FEF[ISE <br /> Licensed scavenger pick-up: Yes' No_ Service Area No . <br /> Other proposed disposal method: /4W <br /> Potent±al problem:— /W � <br /> 4 . FLY. MOSQUITO OR VRCTORPOTENTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/HATH FACILI•TF.j l w Additional <br /> No . & location exioting: - <br /> facilities needed <br /> 6 . PREVIOUS OPMRATION HISTORY <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted: <br /> S . POPULATION DENSITY <br /> Appx . No . PeoDle per sq. mi . <br />