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1. :iLWAGIr (2) <br /> Distance to i'ublic Sewers T'�r, ; Connection necessary: Yes No L <br /> Does existing septic system comply with Ord. W1,jq: Yes No Unknown v' <br /> If no, explain: — — — <br /> Describe septic installation to be installed: <br /> Additional information or couunents: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes 'I+o — Is well proper: Yes `" No <br /> State deficiency: — <br /> Does existing or proposed use make this well public water: Yes ido <br /> Sample of well water taken: Yes — No L Date Taken _ Results— <br /> Additional information or comments: <br /> 3. GARBAGE & It1;FU SE <br /> Licensed scavenget pick-up: Yes _No — Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR. VECTOR I.OTENTIAL <br /> State possible vector potential & necessary control: <br /> 5• <br /> AIR POLLUTION POTENTIAL <br /> State possible burning or processing pollutants & necessary control: 4 <br /> 6. 'IUI1ZT/BATH FACILITIES <br /> [+o. & location existing: Additional facilities needed <br /> 7. 11LEV(IOUS 01,LitATION HIS'MitY { <br /> 6. GEI4ERAL SAHITATIOId <br /> State any problems not previously now,.J : <br /> 9. POPULATIUId Di;NSI'PY fl <br /> Appx, No. People per sq. mi. Uri <br />