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1. SEWAGE �2) <br /> Distance to gsepc Sewers � Connection necessary: Yes — No <br /> � <br /> Does existing septic system compl with Ord. // u9: Yes No Unknown <br /> If no, explain: <br /> llescribe septic in tallation to be installed: <br /> Additional information or comments: J <br /> 2. WATER SUPPLY <br /> Is water supplied by r'vate well: Yes V do Is well proper: Yes No <br /> State deficiency: On <br /> Does existing or proposed use make this well public water: Yes _ No <br /> Sample of well water taken: Yes _ NoDate Taken - f2esults <br /> Additional information or comments: P'. <br /> 3. GARBAGE & REFUSE CIO <br /> Licensed scavenger pick-up: Yes _ No Servic Area No. <br /> Other proposed disposal method: �OPU y��R <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR VECTOR IOTEI4TIAL <br /> State possible vector potential & necessary control: <br /> S. AIR POLLUTION POTENTIAL <br /> State possible burning or processing pollutants & necessary control: '�- <br /> 6. TOILET/BATH FACILITIES <br /> No. & location existing: Additional facilities needed- <br /> 7. i'hEVIOUS 01 is 4TION HISTORY <br /> b. GENERAL SANITATION <br /> State any problems not previously notau: �! <br /> 9. POPULATION DENSITY <br /> Appx. No. People per sq. mi. � <br />