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1. SEWAGE <br /> Distance to Public Sewers Connection necessary: iYes _ No <br /> om . <br /> Does existing septic system comply with Ord, #"49: yes. No <br /> If no, explain: Unknown <br /> Describe septic installation to be installed: <br /> " f <br /> o" <br /> Additional information or comments: ��� A,- <br /> 2. WATER SUPPLY w <br /> Is water supplied by private well: Yes ..„ <br /> State deficiency: f�f1iG� �, No Is well proper: Yes No <br /> Does existing or proposed use make this well public water: Yes <br /> Sample of well water taken: y03 No <br /> No Date Taken Results1 <br /> Additional information or comments: ®tel 1 <br /> 3. GARDAGE & REFUSE <br /> Licensed scavenger, pick-up: Yes No • <br /> Service Area No. <br /> Other proposed disposal <br /> method: <br /> Potential problem: <br /> FLY MOSQUITO OR VECTOR POMTIAL <br /> State possible vector potential & necessary control. <br /> S• AIR PO LLU TION PO TEN TIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILET/I3ATl{ FACILITIES <br /> tvo. & locution existing: �f ' <br /> 7. PREVIOUS OPERATION HISTORY , Additional facilities needed <br /> �. GEIUMRAL SANITATIO11 <br /> State any problems not previously noted: <br /> 9. POPULATION DENSITY <br /> APpX• Ido. People per sq. mi. <br /> d.P� � <br />