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1. SEWAGE <br /> Distance to Public Sewers Connection necessary: iYes No _ <br /> Does existing septic system com 1 + <br /> Il no, explain: P Y with Ord. #-- 9: yes' No _ Unknown <br /> Describe septic installation to be installed: <br /> Additional information or comments; <br /> 2. WATER SUPPLY <br /> Is water supplied by privato well: Yes ..... <br /> State deficiency: No Is w63-1 proper:* Yes No <br /> Does existing or proposed use make this well public water. Yes _ <br /> Sample of well water taken: yes No <br /> ,_ 110 ._ Date Taken Results <br /> Additional information or comments; <br /> 3. GARDAGE & REFUSE <br /> Licensed scavenger, pick-up: Yes No <br /> s Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY MOSQUIM OR VE r3MR POTENTIAL <br /> State possible vector potential & necessary. ary control. • <br /> S. ATR POLLUTION POMITIAL <br /> State possible burning or Processing pollutants &necessary control: <br /> 6. mILET DATi{ FACILITIES <br /> No. & locution existing: ' <br /> ?• Additional facilities needed <br /> PREVIOUS' OPERATION HISTORy <br /> GENERAL SAKITATT014 <br /> State arty problems not previously noted: <br /> 9. POPULATION DENSITY <br /> APpx. ido. People per sq. mi. <br />