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1. SEWAGE <br /> Distance to Public Sewers /R <br /> Does existing septic "��--- Connection necessary: iYes No k;' <br /> If no, explain: system comply withOrd. N5u9: Yes• No v Unknown <br /> Describe septic installation to be installed: /[ <br /> Additional inSormation or comments: <br /> 2. WATER SUPPLY <br /> Is water supplied by private woll: Yes <br /> State deficiency: NO Is well proper: Yes No <br /> Does existing or proposed use make this well public water: <br /> Sample or well water taken. Yes No 4 Date Taken Yes No X <br /> ' <br /> Additional information or comments._ Results <br /> . <br /> 3• GARBAGE & REFUSE /;�/1'�°"t f1.4 � /c,�c�,►. -- <br /> Licensed scavenger pick-up: <br /> yes / <br /> Other proposed dis "'` No — Service Area No. <br /> posal method: <br /> Potential problem: <br /> �. FLY MOSQUIM OR VECTOR POTENTIAL <br /> State possible vector <br /> Potential & necessary control: i>':�-` •- <br /> ------------- <br /> 5• AIR POLLUTION POMjTIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6• FILET BATH FACILIMS <br /> NO. do locution existing: ��,� <br /> Additional facilities needed _F <br /> 7. PREVIOUS OPERATION I{ISTURY , A / <br /> o. GEvERAL SANITATIO11 <br /> State any problems not previously noted: r <br /> 9. FOPULATIO14 DENSITY <br /> Appx. Ido. People per sq. mi. <br />