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1. :;EWAISi✓ (2) <br /> Distance to Public Sewers Connection necessary: � Y _ Ido <br /> Does existing septic system comply with Ord. W5,19: Yes V No Unknown <br /> If no, explain: — — — <br /> Describe septic installation to be installed: <br /> Additional information or comments: ,rG <br /> a-0 <br /> 2. WATER :SUPPLY <br /> Is water supplied by private well: Yes I+o Is well proper: Yes 10 <br /> State deficiency: <br /> fLt t777 �lI <br /> r. - <br /> Do sin proposbd use ma is we_ pu is wa er: es _ ido 1/ <br /> Sample of well water taken: Yes _ Nolte Date Taken _ Results <br /> Additional information or comments: <br /> 3. GARBAGE & kr ku SE <br /> Licensed scavenger pick-up: Yes INo Service Area No. Lx(�_qli <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR. VECTOR I-OMMAL <br /> State possible vector potential & necessary control: <br /> $• AIR POLLUTION POTENTIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. 'f0ILET/BATH FACILITIES <br /> No. & location existing: J��' S'�� Additional facilities deeded <br /> 7. "ftEVIOUS 01,LHATION HIS'ibltY <br /> b. GEI';ERAL SA1,11ITATIOI4 <br /> State any problems not previously no-Led: <br /> 9. POPULATION DENSITY L -� <br /> A x. No. People <br /> PP P Per sq. nil. �� <br />