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1. OWAUE ( 7 <br /> Distance to e'ublie Sewers / / 45;> LpConnecLion necessary: Yes _ No <br /> Does exis¢ing septic systea oomp y with Ord. 4549: Yes ` No Unknown <br /> If no, explain: -- <br /> Describe septic installation to be installed: <br /> Additional information or oomiaents: <br /> 2. W ER SUPFLY <br /> if water supplied by priv to well: Yes _ NO _ Is well proper: Yes No <br /> __"kWdea"ency: <br /> c,�t--'7 Ale- <br /> AV <br /> Does existing or proposed use make this well public water: Yes _ No <br /> Sample of well water taken: Yes — No Date Taken Results~ <br /> Additional informatio or comments: � C .z ` -.Jr <br /> 3. GARBAGE & RE: mjSE <br /> r <br /> Licensed scavenger pick-up: Yes _ No _'Service Area No. <br /> Other proposed disposal method : <br /> Potential problem: <br /> L. FLY, MOSQUITO OR VECTOR I-OTENTIAL <br /> State possible vector potential & necessary control: <br /> S. AIR 110LLUTIG:: P07r:111'IAi. <br /> �3LaLe possio.e burrunt; or procus;;in6 pclluLanLs & necessary control: <br /> 6. IU <br /> LLLE T/BATH FACILITIES <br /> No. & location existing. Additional facilities needed <br /> 7. i'fcEVCIUU� U1 n,'CIOW NI�'I:,I{Y <br /> U• GENERAL JAkiTATION <br /> State ally problems iwt �,ruviouuly nu :, ,i : <br /> 9. POPULATION DENSITY - <br /> Appx . No. E,eople per sq, mi . <br />