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1 . S> wacE f, <br /> Distance to Public Sewers P Connection necessary : Yes_ No r <br /> Does existing septic system comply with Ord . 11549 : Yes— No= <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> Cry cv ;'w�T <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes _ ilo_ Is well proper: <br /> Yes— No_ State deficiency : <br /> Does $xisting or porposed use make this well public water: Yes— <br /> No— <br /> esNo ! 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: It <br /> Potential problc-r., : - ' – <br /> 4 . FJLY� 140SOIJITn OR V Z•'T() PC,rRtdTTA , <br /> State possible vector potential & necessary control : <br /> 5 . T,ILET/BATA EAGILITFS �/ <br /> No . & location existing: _ Additional <br /> facilities needed <br /> 6 . P4AVTOTIS n ATTONi3;`T , <br /> LQ 1� V/ t/, aMA rJ1 f <br /> 7 . GENERAL SA UTAT70N <br /> State any problems riot previouoly noted: - <br /> 41, <br /> oted: _41, , <br /> s . pn JLA_ TION DENSTIY <br /> Appx . No . People per sq . mi . / / $ <br />