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1 . SHWAGE <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 /> Z . 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 /> Licenced scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLY, MOSQUITO QR VG^TQR PO'rENTTAL <br /> State possible vector potentiftl & necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: Additional <br /> facilities needed <br /> 6. pRF.VTon s OPERATION HISTt1RY <br /> 7 . GENERAL SANI'CATTN <br /> State any problems not previously noted: <br /> a . ROPULATT0I1 DENSTTY <br /> Appx. No . People per eq. mi . <br />