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S ' <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 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 . ELY, MOSOUTTO OR V E^Tn M)rENTT <br /> State possible vector potentiitl ?z necessary control: <br /> a . TOTLETIBATH FL IL TES <br /> No . ec locution existing: Additional <br /> facilities needed <br /> 6 . pgxVTnRS (;PRRATIQN HisTnRY <br /> 7 . GENERAL SANTIA'1' ON <br /> State any problems not previously noted : <br /> 8 . POEr1LATT0 4 DEN TTY <br /> Appx. No . People per sq . mi .� <br />