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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 /> Licenced scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . Eli­,- MOSQUITQ OR V ^.TO PS)'rMjLT- <br /> State- possible vector potentiFtl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: _ Additional <br /> facilities needed _ <br /> 6 . PREVIOnS OPERATIC) STn ; <br /> 7 . GENERAL SA1U! '1,J� 'I()N <br /> State any problem: not previously noted: — <br /> 8 . EnPULATION DFNSTI, <br /> Appx. No . People per rq. mi . <br />