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N� <br /> s <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 e ptic installat on to 'be installed: <br /> 2 . MATER SUPPLY <br /> Is water supplied by private well: Yes '� L40 Is well proper: <br /> Yes No ✓ State deficiency: <br /> dwl te'k-, w js 101 ►hcl &d <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 . MOSgUITQ OR V ^,Tc) __RL f .1 <br /> State possible vector potentiftl ?z necessary control : <br /> 5 . T01T,FT/BATH FACILITES <br /> No . & location, existing : Additional <br /> facilities needed _ <br /> 6 . pREVIOfTS npERATION HISTO ; <br /> 7 . GENERAL SAtJIT.ATION <br /> State any problem.- not previously noted : <br /> 8 . PC)PULATIOtd DE�d,,TTY <br /> Appx . No . People per sq . mi . <br />