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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes Nq_ <br /> Does existing septic system comply with Ord . $1549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic insta-.lation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : yesL_ No Is well proper: <br /> Yes. No State deficiency : <br /> Does existing or porposed use make- this well public water: Yes <br /> No_/ 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: <br /> Potentlnl problF n,: _ <br /> 4. FILL, MOSQ(7.1TO OR V ^TO PSVT ,ETIAL <br /> State possible vector potential & necessary can •ol : <br /> 5 . TOILET/BATH FACIjLTTES <br /> No . & location existing: Additional <br /> facilities needed _ <br /> 6 . PREVIOQ,5 OPERATION HISTORY <br /> 7 . GENERAL SANITATION <br /> State any problem - not previously noted: _ <br /> 8 . EQ211LAT-TO14 ZUIIv, <br /> Appx. NO . eople per 6q . mi . <br />