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i <br /> 1. SEWAGE <br /> Distance to Public Sewers Connection necessary: iYes No <br /> Does existing septic system comply with Ord. #549: 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 X 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 11 water taken: Yes _ No _ Date Taken Results <br /> ----------------- <br /> Additional ii mation or comments: <br /> 3. GARBAGE & REFUS <br /> Licensed scavenger 'ck-up: Yes — No Service Area No. <br /> Other proposed dispos method: <br /> Potential problem: <br /> 4. FLY MOSQUITO OR VECTOR PO TIAL <br /> State possible vector potent i & necessary control: <br /> 5. AIR PO LLU TION PO TEN TIAL <br /> State possible burning or processing pol tants & necessary control: <br /> 6. ToiLET/BATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. PREVIOUS OPERATION HIS RY . <br /> 6. GENERAL SANITATION <br /> State any problems not previously noted: <br /> 9. POPULATION DENSITY <br /> Appx, No. People per sq. mi. <br />