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1 <br /> 11� <br /> 1. �t:WAGE <br /> Distance to Public Sewers Connection necessary: Yes _ 140 _ <br /> Does existing septic system comply with Ord . #5149: Yes _ No Unknown <br /> If no, explain: — <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER 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 Xervice Area No. <br /> Other proposed disposal method: <br /> Potential problem: , <br /> 4. FLY, MOSQUIM OR VECMR POTENTIAL <br /> State possible vector potential ,& necessary control: <br /> 5. AIR PO LLU TION PO TEN TIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TJILET/BATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. PREVIOUS OPERATIO14 HISTORY <br /> b. GEI'ERAL SANITATI01�21 <br /> State any problems not previously noted: <br /> 9. } OPULATION DENSITY <br /> Appx. Wo. People per sq. mi. <br />