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1. SEWAGE <br /> l�1 <br /> Distance to Public Sewers Connection necessary: Yes _ No _ f <br /> Does existing septic system comply with Ord. #%-9: Yos No Unknown ' <br /> If no, explain: —' — — <br /> Describe septic installation to be installed: �a <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes _ No Is well proper: Yes No <br /> State deficiency: <br /> Does existing or proposed use make this well pyblic water: Yes _ No _ <br /> Sample of well water taken: Yes — No _Date Taken Results <br /> Additional information or comments: k?JJ1 t '(..02 <br /> 3. GARBAGE & REFUSLt) ? e Y SW jam'/y�p✓ �� a--LI �S�t <br /> Licensed scavenger pick-up: Yes _ No Service Area No. /terCILZC71 <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necossary control: <br /> 5. AIR POLLUTION POTENTIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILET V AM FACILITIES <br /> No. & location existing: Additional facilities needed _ <br /> 7. PRE US OPERATION HISTORY . <br /> 6. GENT-MAL SANITATION <br /> State any problems not previously noted : �- <br /> 9. iOPULATIO14 DENSITY <br /> Appx. No. People per sq. mi. <br />