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1. SE <br /> Distance to Public Sewers Connection necessary: Yes No. <br /> Does existing septic system comply with Ord. $1549 : Yes= No_, <br /> Unknown If no, explain: <br /> Describe septic install tion to *be ins alled: <br /> 2. WATER SUPPLY e <br /> Is water supplied by private we1�Y�u No Is well ,proper: <br /> Yes— No-. State deficiency: lza-7 Ir <br /> i2 jA A)k, ra-t-)-d le,, <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: Yeses No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: /l me - <br /> 4. FLY. MOSOUTTO QR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/ BATHHFLrLLLTEar <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVIOUS OPrgATTON HISTORY <br /> Amp , <br /> -(I c <br /> 7. GENERAL. SANTIAT ON <br /> State any problems not previously noted: <br /> 3 . POPULATI011 DENSTTY D <br /> Appx. No. People per eq. mi. <br />