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1. SEWAGE: <br /> Distance to Public Sewers Connection necessary: i yes No <br /> Does existing septic system comply with Ord, r . <br /> Il no, explain: I1�49: yes. ` No _ Unknown <br /> Ile e <br /> Describe septic installation toe installed: <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes -•• <br /> No , Is well proper: Yes <br /> State deficiency: �9 _ No <br /> Does existing or proposed use make this well public water: Yes <br /> Sample of well water taken: Yea No <br /> ___.. No . Date Taken Results~ " <br /> Additional information or comments: ���E� `�y�ivr��o' �.; • <br /> 3. GAR]3AGE & REFUSE �' !✓a E2. <br /> Licensed scavenger pick-up: yes NoJ <br /> s Service Area No. 4/� <br /> Other proposed disposal method; <br /> Potential problem: ' <br /> 1a. FLY1 MOSQUIM OR VECMR POTENTIAL <br /> State possible vector potential & necessary control: <br /> S. AIR POLLUTION POM-ITIA.L <br /> State possible burning or processing pollutants & necessary control: . , <br /> 6. mILET/B/ M FACILITIES <br /> No. & location existing: <br /> Additional facilities needed <br /> 7• P1�EVIOUS OPERATION HISMRY , <br /> d. MNERAL SANITATIO11 <br /> State any problems not previously noted: <br /> 9. P=OPULATION DENSITY <br /> APpx. No. People per sq. mi. �� 4/ �FI✓r�� /Jlf��c�—;- .�, <br />