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1. S&,,AGE (2) <br /> Distance to Public Sewers Connection necessary: Yes No _ <br /> Does existing septic system compiy with Ord. #519: Yes No — Unknown <br /> If no, explain: <br /> Describe septic installation to be installed:�� <br /> Additional information or counents: <br /> 2. VIA`PER SUPPLY <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 No _ <br /> Sample of well water taken: Yes No Date Taken Results <br /> Additional. information or comments: <br /> 3. GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: _ � - <br /> 4. FLY, XOSQUITO 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 /> 6. GEL'iERAL SAKITATIO.d <br /> State any problems not previously noted: <br /> 9. POPULATION DENSITY <br /> Appx. No. People per sq. mi. <br /> EH 06 o6 3/71 <br /> 4/74 750 <br />