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1• SEWAGE <br /> • Distance to Public Sewers I + <br /> � ___� Connection necessary: i Yes No ..._ .". <br /> Does existing septic system comply with Ord. #- 9: yes. I No — Unknown <br /> 1l no, explain: <br /> Describe septic installation to be installed: " <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> Is grater suppliod by p ivate WOU: Yes - ... <br /> State de iciency: No Is well ProPert Yea No <br /> Does existingor <br /> proposed use make this well, public 'water: Yes -,� No <br /> Sample of well water taken: Yes .._ No .__. Date Taken <br /> Additional, inrOrmation or comments: ----� Results <br /> 3. CARUGE & REFUSE <br /> Licensed scavenger pick-up: Yes � No � Service Area No. <br /> Other proposed disposal method; , <br /> Potential problem: <br /> 1�. <br /> FLY moppyIT] OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control; <br /> S• AIR POLLUTION POTENTIAL <br /> Stato Possible burning orrocessi <br /> P ng pollutants &necessary control: <br /> 6• MILET BATH FACILITIES <br /> No. & location existing: <br /> 7. PREYIpUS, OpMTjON HISMRY Additional facilities needed <br /> I <br /> h. CRUEFtAL SANITATIO14 <br /> State any problems not previously noted: N <br /> E 9. FOPULATION DENSITY <br /> APPx• NO- People per sq. mi. <br />