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1. Alk <br /> SEWAGE <br /> Distance to i'ublic Sewers Connection necessary: Yes No <br /> Does exiaging septic cyate=_Iomp y with Ord. J549: Yes No — Unknown <br /> If ho explain:" <br /> Describe sceptic installation to be installed: <br /> Additional informtion or consents: <br /> 2. WATER SUPFLY <br /> 10,'-water supplfed .by private well: Yes Edo Is well proper: Yea No <br /> S,t4" deficiency: <br /> Does existing or proposed use make this well public water: Yea No <br /> Sample of well water taken: Yes -No Date Taken Results <br /> Additional information or comments: <br /> 3. GARBAGE & RkMSE . <br /> Licensed a'eavw%er pick-up: Yes _ No _ Service Area No. <br /> Other proposed disposal method : <br /> Potential problem: <br /> 4. FLY; MC)SQUIT O OR VECTOR 10TENTIAL <br /> State possible vector potential & necessary control: <br /> t <br /> 5. AIR PO LLU TION PO TE!1 TI A L <br /> State possible burning or processing pollutants & necessary control: <br /> 6. MILET/BATH FACILITIES <br /> No. do location existing: Additional facilities needed <br /> 7. JR6VIOUS 01'i:rATION HISIURY <br /> H. GENERAL SANITATIOr4 <br /> State any problems not previously no...J : <br /> 9. POPULATION DENSITY <br /> Appx. No. People per sq. mi. <br />