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1 . SEAQ <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 . WATER SUPPLY <br /> Is water supplied by private well : Yes ido Is dell proper: <br /> Yes No State deficiency : - -- <br /> Does existing or porposed use make this well public water: Yes— <br /> No­ <br /> esNo » Sample of well water taken: Yes No Date taken <br /> Results — Additional information or comments <br /> 3 . GSR & REFUSE <br /> Licenced scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potent:!al problem-­ <br /> 4 . <br /> roblem:_.._._4 . FLY, tOSOUITQ oR v ' E.C)LEI TIAL. <br /> State possible vector potential 6z necessary control: <br /> 5 . TOT <br /> LET <br /> /BATH o {,�� Additional <br /> No. F�c locution exioting : <br /> facilities nee:ded_.,_ - --- ---- <br /> 6. PREYTOUS Q RAT.TON HISjnF?X <br /> 7 . Q E N E B AL 3AHIL A,7 Qli <br /> State any problemv not previou-sly noted: - <br /> 3 . <br /> oted: _S . POPCFLA=1� 0•-1.i= <br /> Appx . No . People per eq. Mi <br />