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a . SEWAGEi <br /> Distance to Public Sewers Connection necessary : Yes No_ <br /> Does existing septic system comply with Ord . #549 : `les 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 tlo Is well proper: <br /> Yee No_._._ State deficiency: <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well eater taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licenced scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem- <br /> 4 . <br /> roblem:4 . ELY . MC50UTT0 OR VMTO M)C ENTIAL <br /> State possible vector potentirtl & necessary control: <br /> 5 . TOTLET/BATH FACILIJES <br /> No . & location existing: _ Additional <br /> facilities needed <br /> 6. PREYIoaa npERATIoN HIST <br /> 7. G .N EA . SAN T'L 1A IQN <br /> State any problems not Previously rioted: --- <br /> 3 . EQPULATION DEJi,,ITY <br /> APpx. No . People per sq . mi . <br />