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1. SEWA(3E <br /> (2) <br /> Distance to i'ublic Sewerst,, Connection necessary: Yes _ No _ <br /> Does existing aeptic system comply with Ord, 4549: Yes No Unknown <br /> If no, eip1a1n:-,_ — <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> I 'Vatet.' supplied .by private well: Yes Al Wo _ Is well proper: Yes No <br /> St$te deficiency: —:� <br /> Does existing or proposed use snake this well public water: Yes No <br /> Sample of well water taken: Yes No ,-' Date Taken Results <br /> Additional information or comments: <br /> 3. GARBAGE & FIMSE <br /> Licensed scavenger pick-up: Yes _ No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR VECTOR 10TENTIAL <br /> State possible vector potential & necessary control: <br /> 5. AIR POLLUTION POTEIJTIAL <br /> State possible burning or pnr�occpssing pollutants & necessary control: <br /> 6. 1OIIET/BATH FACILITIES <br /> Ivo. & location existing: IN14 Additional facilities needed <br /> 7. ?hir.VIOUS 01,ZhATIO14 HISTORY <br /> $. GEIv7-RAL SANITATION <br /> State any problems not previously no-1,J : <br /> 9. POPULATION DENSITY <br /> Appx, No. ?eople per sq. rr,i. <br />