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1 . SEWAGE <br /> Distance to Public Sewers 49� 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 SUE PLY <br /> Is water supplied by private well.: <br /> Yes No�� Is we,11 proper: <br /> Yes No State deficiency : �E` 6� �'����el <br /> Does existing or porposed use make this we'll 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. ESPY MOSQUITO OR VZ^.T() ZCi'f ENTIAL <br /> State possible vector potential & necessary control : �c�F <br /> 5 . TOTTLET/BATH FACILITES <br /> No . & location existing: �'��F Additional <br /> facilities needed <br /> 6 . PREV_TOU2 OPERATIO14 HISTORY <br /> 7 . GENERAL SAPIIT '1,14 'ION <br /> State any problems not previously noted: <br /> 8 . POPULATION Dr i STTY r <br /> A p p x. No . People per sq. r,,i .,��•�1Pd,G�-Cf -��r- ✓� <br />