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M� <br /> (2) , <br /> Distance to i'ublic Sewers <br /> Connection necessary: Yes _ 140) <br /> Does existing septic system co pl wZth Ord. d>ii9: Yes No U nown <br /> If no, explain: —' — <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER SU?FLY <br /> Is water supplied by private well: Yes _ [;o _ Is well proper: Yes 'L___/to <br /> o <br /> State deficiency: —" <br /> Does existing or proposed use make this, well public water: Yes _ ,yo �Q <br /> Sample of well water taken: Yes _ NO _ Date Taken _ Results <br /> Additional information or comments: <br /> 3. GARBAGE & 1W"USE <br /> Licensed scavenger pick-up: Yes _ No Service Area No. <br /> Other proposed disposal method : <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR. VECTOR 1-OTEMAL <br /> State possible vector potential & necessary control: <br /> 5. AIR PO LLU TIO;J POTENTIAL <br /> State possible burning or processing pollutants & necessary control: --•-� <br /> 6. TUILET/BATH FACILITIES <br /> 1+0. & location existing: V Additional facilities heeded <br /> 7. ILEVIOUS 01'LhATION HISTORY <br /> b. GENERAL SAMITATIOIJ <br /> State any problems not t,ruvicu ;iy not.-,.J: <br /> 9. FOPULATION DENSITY <br /> Appx, Wo. People per sq. mi. <br />