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t <br /> 1• SEWAGE <br /> Distance to Public Sewers -2::�,ga connection necessary: Yes Nom <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—Z, No State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No_,/,_ Sample of well water taken: Yes NqX--,^ Date taken <br /> Results Additional information or comments- <br /> 3 . <br /> omments3 . GARBAGE & REFUSE <br /> Licenced scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem- <br /> 4. <br /> roblem:4. FLY. MOSQUITO QR V 1 QTOj�p,S)TENTTA <br /> State possible vector potentiztl PA necessary control: <br /> 5 . TOILET/BATH FACIt�ITES <br /> No. & location existing : Additional <br /> facilities needed <br /> 6. PgRyTons CPrRATTON HIaTnRY <br /> 7 . GENERAL SANTIATT01f <br /> Stat© any problems not prevlously noted: <br /> 3 . PQPULATT0t4 DEAN STTY <br /> Appx. No . People per eq . mi . <br />