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1 <br /> 1. SLWAUE !71 <br /> Distance to i'ublic Sewers -/ 9+G,i ��ection neceaa <br /> Does exis`ing septio system oo aZ7: Yes No <br /> It.no, e:iplain: �P y with Ord, 1549: Yes _ No _ Unknown <br /> Ueseribe septic installation to be installed: <br /> Additional information or comments: <br /> 2. NATER SUPFLY <br /> IQ 'water supplied by privets well: Xes 110 Is wall propers Yes No <br /> S,tgte deficiency: _ <br /> Doe* existing or proposed use make this well public water: Yee _ No <br /> Sample of well water taken: Yes _ No _ Date Taken <br /> Results <br /> Additional information or comments: <br /> 3. OARRACE k WUSE <br /> Licensed scavenger pick-up: , Yes _ No —'Service Area No. <br /> Other proposed disposal method: <br /> Fotential problem: <br /> 4. _ M]SOUI10 OR VECIUR }O�;TIAL <br /> State possible vector potential h necessary control: <br /> 5. AIR POLLUTIG:; POTIIITIAL <br /> Mate poSsioce bur.nine or proce:,s1116 LoliutantS 6 necessary control: <br /> 6. TOILET/HATH FACILITIES <br /> NO- & location existing: Additional facilities needed <br /> 7• i'hiv10U:� 01 ..7.;.r,014 III 1' itY <br /> b• GENERAL SAr.;ATIUt1 <br /> Statu arty problems 10L 1,reviously 110 , 'j : <br /> 9. POPULATION DENSITY <br /> Appx. ;Jo. People per sq. mi. <br />