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1. SEWAGE <br /> Distance to Public Sewers Connection necessary: iYes _ No <br /> Does existing septic system comply with Ord. #/)49: Yes. No Unknown <br /> If no, explain: — — — <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes No Is well proper: Yes No <br /> State deficiency: '— — <br /> Does existing or proposed use make this well public water: Yes _ <br /> Sample of well water taken: Yes P No s <br /> 1!0 — Date Taken Results <br /> Additional information or comments: <br /> 3. GMMGE & REFUSE <br /> Licensed scavenger pick-up: Yes No _ Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: .< <br /> 4. FLY, MOSQUI1ll OR VEC10R P01�NTIAL <br /> State possible vector potential & necessary control: �o�f <br /> 5. AIR POLLUTION PO .IITIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. mILCT/pA71{ FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. PREVIOUS OPERATION IfISMRY , <br /> 6 7li 7 <br /> d. GENERAL SANITATION <br /> State any previously not problems P ly noted: <br /> 9. f-OPULATION DENSITY <br /> APpx• No. People per sq. mi. /rf%v�✓l. � <br />