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1 ' SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes No_ <br /> Does existing septic system comply with Ord . 0549 : `les No_ <br /> Unknown If no, explain : <br /> Describe septic installation to a installed• <br /> ✓F��c ��/� <br /> 2 . WATER SUPPL`I <br /> Is water supplied by private well Yes 10__ Is ��e 1 roper: <br /> Yes No State deficiency : -f <br /> �<✓�.l`F/I�f/�E/ ��a,!' /r/it Fy F f�s x; e�11/lf c� Osyf f A/Bi ,fil�Alr/fGKy/�F <br /> Does existing or porposed use make this well public water: Yes- <br /> No � � Sample of well water taken: Yes No Dateeale}� ; <br /> Results Additional information or comments <br /> 77 <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes / No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem : y�f <br /> 4 . ZLLY_,,_ MOSQUITO OR V E^TO PC'fjTJ T T <br /> State possible vector potentiFtl & necessary control : <br /> 5 . TOILET/BATH FACTT,11, <br /> No . ec location existing : _ Additional <br /> facilities needed <br /> 6 . PREVIOUS O +,RATIO'N HISTOR <br /> 7 . G +.N +,RAj� SANI'rA'rTON <br /> State any problems not previously <br /> s . Paror,ATT��r� ,r TY / <br /> Appx. No . People per rq . rr,i . <br />