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1. SEWAGE <br /> Distance to Public Sewers - q Connection necessary: <br /> iYes NoDoes existing septic system comply Ord. /r,9: . <br /> yes. No Unknown .. . ,.. . <br /> If no, explain: -- -- ._.,,,• <br /> Describe septic installation to be installed: <br /> Additional information or commentb: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes ->No _ Is wellro <br /> p per: Yes _ No <br /> State deficiency: <br /> Does existing or proposed use make this well public water: Yes ,--No <br /> _ <br /> Sample of well water taken: Yes _ No fla to Taken Results <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE �6 ct6'�,' ('t S S--c-I/.u/ 0 Ca,1 rr <br /> Licensed scavenger pick-up: Yes _ No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5• AIR POLLUTION POTENTIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. M ILET/BATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. PREVIOUS OPERATION HISTORY , <br /> d. GENERAL SANITATIO11 <br /> State any problems not previously noted: <br /> 9. FOPULATION DENSITY <br /> Appx. No. People per sq, mi. <br /> / �i-� CJ'1�1v�.1t•il �CS-0 -S�t c�-"�_ � �7L� <br /> fes`' '�",� <br />