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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes No_ <br /> Does existing septic system comply with Ord. 0549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No,- Is well proper: <br /> Yes No State def4ciency : <br /> Does existing or porpesed use make this well public water: Yes— <br /> No— Sample <br /> esNoSample of well water taken: Yes No Date taken <br /> Res is Additional information or comments <br /> 3 < <br /> Lic sed scavenger pick-up: Yes No Service Are o . <br /> Other roposed disposal method: <br /> Potenti problem: <br /> 4 . S QUI QR EQT0a_EC)rjBjjAL <br /> State possible vector potential & necess y Zcontrol : <br /> 5 . TOILET/BATH FACILITES \ <br /> No . & location existing: Additional <br /> facilities needed _ <br /> 6 . PREVTO(Ta OPERATION <br /> i <br /> 7 . GENERAL � lfTTA1'IQN <br /> State y problems not previously noted : , <br /> 8 . PQPEIL ATION DENISITY <br /> APpx. No . People per oq . mi . <br />