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1. 'JOWAGE (?) <br /> Distance to i'ubllc Sewers <br /> Does axis Connection necessary: Yea _ No <br /> septic systea oo�'y with Ord. ,x;49: Yes No Unknown <br /> Describe septic installation to be installed: <br /> Additional inforwation or comments: <br /> 2. WAR.SUPF LY-___.. .. <br /> Z0 'water supplied..by, private well: Yea 110 Is well proper: Tee NOS,t4te deficiency: _ — –*– <br /> Does exiating or proposed use Rake thin well public water: Yea _ No <br /> Sample of well water taken: ` Yea _ No Date Taken Rssulte~ <br /> Ad'ditiona'l information or comments: <br /> 3. GAR9ACE & pEnSE <br /> Licensed acaverkger pick-up: Yes _ No 'Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4• F'LT. 110 UIYO OR HECTOR 1. UNTIAL <br /> State Poaslble vector potential & necessary control: <br /> S. AIR POLWTIt,.. I'07DI 'IAL , <br /> :3 La Le possio_e burning or Nroces;;lu6 l,e,l iu LanLs G necessary control: <br /> 6. 1U I LET/HATH FACILITIES <br /> NO. & location existing: Additional facilities needed <br /> 7. "hivluU:; U! ..-.;'rIow 111L;7;,i(Y <br /> �- <br /> GENERAL SAi;i;ATluu <br /> La Lu "IV problems 110L j,rcv Lou;,ly nu:. .i : <br /> POPULATION DENSITY <br /> Appx. ;Jo. !-eople per sq. nii . <br />