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1. �Lk'AGE (2) <br /> Distance to i'ublic Sewers Connection necessary: Yes Ido <br /> Does existing septic system comply with Ord . W>a9: Yes I�Io Unknow_n <br /> If no, explain: _ — <br /> Describe septic installation to be installed: <br /> Additional information or cojwrients: <br /> 2. WATER SUPFLY <br /> i <br /> Is water supplied by private well: Yes ��No Is well proper: Yes _ No _ <br /> State deficiency: <br /> Does existing or proposed use make this well public water: Yes _ ido <br /> Sample of well water taken: Yes — No _ Date Taken Results— <br /> Additional information or comments: <br /> 3. GARBAGE & REkAJ SE <br /> Licensed scavenger pick-up: Yes ✓ NO _ Service Area No. <br /> Other proposed disposal method : - <br /> Potential problem: <br /> !i. FLY, MOSQUITO OR. VECTOR I-07ENTIAL <br /> State possible vector potential & necessary control: <br /> 5. AIR POLLUTION POTENTIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. 'MILET/BATH FACILITIES <br /> l+o. & location existing: Additional facilities heeded <br /> 7. i'ItEVIOUS U1'LHATION I{IS'MitY <br /> ��r✓v i^��rt� <br /> b. GEI;ERAL SANITATION <br /> State any problems not previau:;iy no,....; : <br /> 9. I-OPULATION DENSITY 1 <br /> Appx. No . people per sq. mi. <br />