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1. SRWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord. #549 : Yes No_ <br /> Unknown IP 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 /> a . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSQUITO QR VECTOR P0'[ENTIAL <br /> State possible vector potentiftl & necessary control: <br /> 5 . TQT_LET/BATH FACTLITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVI(1n,S OP .RATION HTsTngX <br /> 7 . GENERAL SANTI TION <br /> State any problems not previously noted: <br /> 9 . PQP[ILATION DENSTTY <br /> Appx. No . People per sq. mi. <br />