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i <br /> ( 1� <br /> 1 . �t:wAGE <br /> Distance to Public Sewers __r0r,0 Connection necessary: es _ 140 (/ <br /> Does existing septic system comply with Ord, #5149: Yes No _ Unknown <br /> If no, explain: <br /> Describe septic installation to b Installed: j L <br /> 41 <br /> I � ' 7 C U r v5e <br /> Additional infor on od comments: , <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes VINo _ Is well roper: Yes _ No _ <br /> State deficiency: 6," <br /> 5 <br /> Does existing or proposed use make this well public water: Yes _ No <br /> Sample of well water taken: Yes _ No L.ZDate Taken Results <br /> Additional information or comments: <br /> 3. G=ARBAGE & REFUSE / <br /> Licensed scavenger pick-up: Yes � No _ Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> !�. FLY, MOSQUIM OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5. AIR POLLUTION POMMAL <br /> State possible burning or processing poll tants & necessary ontrol: /cJf'Q5 <br /> ►� I �- &tU <br /> d <br /> 0rr_0 W <br /> r <br /> 6. TVILET/BATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. ?REVIOUS OPERATIO14 HISTORY <br /> r <br /> ii1flo �� ry <br /> b. GENERAL SANITAT1014 <br /> State any problems not previously noted : <br /> 9. } PULATION DENSITY <br /> e <br /> Appx. No. People per sq. mi. <br />