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R <br /> 1 . SEWAGE <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 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 = PCILFNTIAL <br /> State possible vector potential. & necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: — Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HISTfiRY <br /> 7 . GENERAL SANI'M,'ION <br /> State any problems not previously noted : - <br /> 8 . <br /> oted: _3 . POPULATIQN DENSITY <br /> Appx. No. People per sq. mi ._ <br />