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1. SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No <br /> comply Does existing septic system with Ord. Nr <br /> Il no, explain: ,9: Yes ' <br /> No _ Unknown <br /> Describe septic installation to be installed: <br /> Additional information or comments: ,O �� 7,77=7e <br /> 2. WATER SUPPLY <br /> Is water suppliod by private well: yes <br /> State deficiency: No es--.— Is well Proper: Y <br /> (//j' �o .fes NO <br /> '�`� f - . .�_{„� �F,l t E.a ,✓DFS f��. fT <br /> Does existing or proposed use make this well public water: Yes <br /> Sample of well water taken: Yes No <br /> No Date Taken Results <br /> Additional information or comments: <br /> 3• AGE & REFUSE -- <br /> Licensed scavenger pick-up: Y(;s _ <br /> Other NO Service Area No. �� <br /> Proposed disposes, method: � <br /> Potential problem: - <br /> 4. <br /> FLYI MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> s• AIR PO LLU TION PO TFj TIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. mILET DAW FACILITIES w_ <br /> ho• 6c location existing: <br /> 7. PREVIOUS OPERATION HIS MRY Additional facilities needed <br /> °. GENERAL SANITATI01, <br /> State any problems not previously noted: �JoyF <br /> 9. POPULATION DENSITY <br /> APpx- iso. People per sq. mi. ., <br /> �f-li�c� i9et'; <br />