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1 . SEWAGE <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 septic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes No—_ State deficiency : _ <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 . FLY L MOSQUITO OE Y E CTOPSIT ' IAL <br /> State possible vector potential & necessary control : <br /> 5 . T�1Ifi`ET� ATH FACILI7 <br /> No . & location existing : ___ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTfa <br /> 7 . GENERAL SANI'LfT'IO-N. <br /> State any problems not Previously noted: — <br /> S . <br /> oted: _S . POPULATIO14 DENSITY <br /> Apex. No . People per sq. ml _ <br />