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1. ;LWAGr (2) <br />Distance to Public Sewers Connection necessary: Yes_ No <br />Does existing septic system comply with Ord. W-',:9: 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 _ Igo _ Is well proper: Yes _ No <br />State deficiency: <br />3. <br />4 <br />0 <br />7. <br />Does existing or proposed use make this well public water: Yes _ ;Jo _ <br />Sample of well water taken: Yes _ No _ Date Taken Results _ <br />Additional information or comments: <br />GARBAGE & Mk'I1SE <br />Licensed scavenger pick-up: Yes _ No _ Service Area No. <br />Other proposed disposal method: <br />Potential problem: <br />FLY, MOSQUITO OR. VECTOR I.OTENTIAL <br />State possible vector potential & necessary control: <br />5. <br />AIR POLLUTION POTENTIAL <br />State possible burning or processing pollutants & necessary control: <br />TOILET/BATH FACILITIES <br />ho. & location existing: <br />''MVIOUS UPLhATION HISTORY <br />!S. GEIvERAL SANITATION <br />State any problems not previously noL...J: <br />9. FOPULATIO14 DENSITY <br />Appx. No. People per sq. mi. <br />Additional facilities needed <br />