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1. SEWAUE (2) <br /> Distance to i'ublic Sewers Connection necessary: Yes _ No <br /> Does existing septic system co y with Ord. Wj49: Yes No Unknown <br /> If no, explain: "... <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER SUPFLY <br /> Iq water supplied by private well: Yes No Is well propert Yes �' No <br /> S_Ute deficiency: — -�-- — <br /> Does existing or proposed use make 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 & REFUSE <br /> Licensed scavenger pick-up: Yes No _ Service Area NO. V, `'-p <br /> Other proposed disposal method : <br /> Fotential problem: <br /> 4. FLY, MOSQUIM OR VECTOR FOTENTIAL <br /> State possible vector potential & necessary control: <br /> 5. AIR POLLUTION POTEIITIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. ToiLET/BATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. ?ftEVIOUS 01,LitATION HISTORY <br /> $. GEI47,RAL SA141TATION <br /> State any problems not previously noi,_J : <br /> 9. POPULATION DENSITY <br /> r <br /> Y <br /> Appx. No. people per sq. mi. <br />