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4 <br /> SHWAGR <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord. #549 : Yes No_,.. <br /> Unknown If no, explain: <br /> Describe septic installation to "be installed: <br /> 2. HATER SUPPLY <br /> Is Water suppliedby private well : Yes 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 /> Potential problem: <br /> 4. FLY . MOSQUITO OR Vji',CTnR POT2,NTTA <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH FACTLITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVTOOS GPCRATTnN HT,STORY <br /> 7 . GENERAL SAITTTATTON <br /> State any problems not previously noted: <br /> S . POPULATION DXMSTTY <br /> Appx. No. People per eq. mi. <br />