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I . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes Noy' <br /> Does existi}1g septic system comply with Ord . 0549 : Yes No_ <br /> Unknown ✓ If no,, expl j <br /> G �rY %� 0YB0J9l� <br /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes ,k iso Is well proper: <br /> Yes_ No State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No `1/ Sample of well water tar.en: 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 . =. MnSoUITn OR V CTn1 PS)'f ,NTS <br /> State possible vector potentiFtl F.c necessary control : <br /> 5 . TOILET/BATH FACILE 'II ,E; <br /> No. & location existing: Additional <br /> facilities needed _ <br /> 6 . PREVIOUS npEgATIOtj HISTnF•Y <br /> 7 . GENERAL SAitITATION <br /> State any proble:n� not previously noted : <br /> 8 . pOI7,CILATI0i4 DE' `'T v <br /> Appx. No . People per sq. mi . <br />