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1. Connection necessary: Yes No <br /> Distance to Public Sewers r _._„ <br /> system comply with Ord. #549 -- Yes NO— <br /> Does existing septic <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 2. WATER UPPI,`L <br /> Is Hater supplied by. private well: Yes �ia� is well proper: <br /> Yes No State deficiency: <br /> Does, existing or porposed use make this Well public water: Yes. <br /> Na Sample of well Water taken: Yep NO Date taken <br /> Results Additional information or comments <br /> 3 . `t � . <br /> Licensed scavenger pick-up: Yes No Service Area No. � <br /> Other proposed disposal method: <br /> Potential problem- <br /> 4. <br /> roblem:4. ELL MOSQUITQ QR VECTOR >' <br /> State passible vector potential necessary control: <br /> 5 . n r <br /> No. Fc location existing: Additional <br /> facilities needed <br /> 8. PHEYTOUS OPERATIONO <br /> 7 . <br /> State any problems not previously noted: <br /> 3 . POPULATION 12FHSTTY <br /> Appx. No . People per sq. m i. <br />