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1. SEWAGE <br /> lel <br /> Distance to Public Sewers Connection necessary: ; Yes L--No _ F <br /> Does existing septic system comply with Ord. #549: Yes No Unknown <br /> If no, explain: <br /> Describe septic installation to be installed: , <br /> Additionainformation or comments: <br /> w <br /> 2. WATER SUPPLY L <br /> Is water supplied by private well: Yes No _ Is well proper: Yes-'`l No <br /> State deficiency: <br /> Does existing or proposed use make this well public water: Yes _ No <br /> Sample of well water taken: Yes _ No Date Taken Resultsr <br /> Additional information or co ents: <br /> 3. GARBAGE & REFUSE =P ~` <br /> Licensed scavenger pick-up: Yes _ No _ Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5. AIR POLLUTION POTENTIAL <br /> State possible burning or processing pollutants & necessary control:------ - <br /> 6. TOILET/BATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. PREVIOUS OPERATION HISTORY . <br /> 8. GENERAL SANITATIOII <br /> State any problems not previously noted: <br /> -2 CJe C2 017 ze _ <br /> 9. POPULATION DENSITY �_- <br /> Appx. No. People per sq. mi. <br />