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1. :aWAUh: (2) <br /> Distance to Public Sewers Connection necessary: Yea _ No <br /> Does exis`inif hog septic cysteo�y Frith Ord. ,x;49: yes No Unknown <br /> Describe septic installation to be installed: <br /> Additional information or coanente: <br /> 2. WA SUPFLY <br /> Ip 'water supplied.by private well: Yea tJo Is well proper: Yee No <br /> S14" deficiency: <br /> Does existing or proposed use Rake this well public water: Yea _ No <br /> Sample of well water taken: Yes _ No Date Taken _ Rs3ulta~_ <br /> Additional information or comments: <br /> 3. GARBAGE & RFjUSE <br /> Licensed'scavenger pick-up: Yes _ No 'Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4- <br /> FLT, MOSQUITO OR VECTOR IOUNTIAL <br /> State possible vector potential & necessary control: <br /> S. A-IF( I'OLLUTIG:. ;"071:1111AL , <br /> Mate posslo_c burninC or Nroce:;,s1116 l,ulluLant:; & necessary control: <br /> 6- TUI LET/HATH FA CI LI TIES <br /> No. & location existing: Additional facilities needed <br /> 7• Ui ;TION 111: T, <br /> • <br /> GENERAL L;AI%iiATIUN <br /> :-;tato arty problems nut 1,revlou;,ly nu:. .i : <br /> POPULATTUN DENSITY <br /> APPx . -40. People per sq. n,i . <br />