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1. SEWAGE <br /> Distance to Public Sewers L Connection necessary: Yes _ No <br /> Does existing septic system comply with Ord. #-Lg: Yes, ` ' No Unknown <br /> ? U <br /> Il no, explain: <br /> Describe arc� l- <br /> septic installation�"to be installed: <br /> / `7 L <br /> C Y�E q.- , r s —,/-7 ,1, <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes / - - <br /> No ✓ Is <br /> State deficiency: well proper: Yes No <br /> Does existing or proposed use make this wellublic water: Yes <br /> Sample of well water taken: Yes Ito I--,Dp M <br /> ate Taken Results <br /> Additional information or comments: <br /> 3. GARDAGE & REFUSE / <br /> Licensed scavenger, pick-up: Yes No �/ <br /> Other proposed disposal method Service Area No. <br /> : <br /> Potential nrobi e^r - -- <br /> 4. FLY MO�Ul�i13 ole v ;clui� 7A MNTIA.L <br /> State possible vector potential & necessary control: <br /> S. AIR POLLUTION PO TEN TIAL <br /> State possible burning or processing pollutants & necessary control: <br /> ;\j I )'\-Z <br /> 6. mILr-,T/BATV FACILITIES <br /> No. & location existing: �,�� �-e <br /> Additional facilities needed <br /> 7. PREVIOUS OPERATION I{ISMRY , <br /> ✓rrwC s <br /> d. GEN-ERAL SAKI TATIO11 <br /> State any problems not previously noted: <br /> 9. POPULATION DENSITY <br /> APpx• i4o. People per sq, mi. <br />