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1. jLWAWr (2) + <br /> Distance to Public Sewers Connection necessary: Yes _ No <br /> Does existing septic system comply with Ord . Wf49: Yes No _ Unknown <br /> If no, explain: <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> r-- <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes No Is well proper: Yes ✓IJo <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 _ Service Area No. <br /> Other proposed disposal method: — <br /> Potential problem: t-') <br /> 4. FLY, MOSQUITO OR VECTOR I-OTENTIAL <br /> State possible vector potential & necessary control: <br /> 5. AIR POLLUTION POTEIITIAL <br /> State possible burning or processing pollutants & necessary control: <br /> M a'_Q_ <br /> 6. TOILET/BATH FACILITIES <br /> A;o. & location existing: LfZ&= Additional facilities needed <br /> 7. ljf&r VIOUS OPILi ATION IIIS`IORY Z <br /> �S. GEI,JERAL SANITATION <br /> State any problems not previously noted : <br /> 9. POPULATION D&, SITY <br /> Appx. No. People per sq. mi. ��,� <br />