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1. :;Lla'AGr: (2) <br /> Distance to eublic Sewers Connection necessary: , Yes IJo ° <br /> Does existing septic system comply kith Ord. W/ijq: Yes A jvmo — Unknown' <br /> If no, explain: — — — <br /> Describe septic installation to be installed: <br /> Additional information or commen s: <br /> 2. WATER SU?FLY <br /> Is water Supplied by private well: Yes _ Go _ Is well proper: Yes (� tjo <br /> State deficiency: �° �� '� r -� °On , <br /> ( u C C v r I ICA <br /> VuAq <br /> ,• w r <br /> 17 <br /> Doe xi tW91 o sedgy I e,�n�e h well public water: Yes ;Jo •�� <br /> Sample of well water taken: Yes — NO _ Date Taken Results <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE, � � i1 Y erA/L f l dv 0/� i V'r i y_Q:+13 _(Pe Ct <br /> Licensed scavenger pick-up: Yes �No _ 0 �'� a�(dE�� ✓1 <br /> • P P 1.L Service Area No. <br /> Other proposed disposal method .- <br /> Potential <br /> ethod :Potential problem: <br /> 4. FLY, MOSQUITO OR. TECTOR I.OTENTIAL 1 <br /> State possible vector potential & necessary control: 'v <br /> $• AIR PO LLU TIO; PO TEI I T'I A L - - <br /> State possibie burning or processing pollutants control: I <br /> 6. 'IUILET/BATH FACILITIES <br /> ho. & location existing: ,A Additional facilities needea <br /> 7. ChEVIOULi Ul'LttA'fIOIJ IiIS'My <br /> tI. <br /> GENERAL SAIdI'rATIOIJ <br /> State any problems not p,,uviou;ay nc�,.:..; : <br /> 9. FOPULATION DENSITY — — <br /> Appx. No. People per sq. mi. �QJ r�: ci �� <br />