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1. SEWAGE <br /> • s <br /> Distance to Public Sewers • " <br /> Does existingseptic "' =C°nnectionrnocessary: Yes No <br /> P system comply with Ord. #%9: Yes• ` No Unknown <br /> If no, explain: <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER SUPPLY a <br /> Is water supplied by privato wall: Yes L!I'No _ Is well proper:' - - <br /> State deficiency: p per: Yes No <br /> Does existing or proposed use make this well public water: YesNo <br /> Sample of well water taken: Yes _ No _ Date Taken _ <br /> Additional information or comments: Results <br /> 3. GARBAGE & REFUSE <br /> Licensed scavenger, pick-up: Yes No <br /> — Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 1�. FLY, MOSQUITO OR VECMR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5 e AIR PO LLU TION PO TFdJTTAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. ZVILET/BATH FACILITIES <br /> NO- & location existing: �'��-�-�e <br /> Additional facilities needed <br /> 7. PREVIOUS OPERATION 11ISTORY , <br /> + <br /> �. GENFERAI. SANITATIO11 <br /> State any problems not previously noted: <br /> 9. FOPUI.ATIO14 DENSITY <br /> APPx• 14o. People per sq. mi. <br /> e- <br />