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1. "b'LUAGE (2 <br /> Distance to :'ublio Sewerst <br /> Connection rrceaeary: Ysa _ No <br /> Dos$ exis`ing ssptio systea pT w'ith Ord. 649: Yes No Unknown <br /> It iso, �ezplah.: — <br /> Ueacribe 3dptic installation to be installed: <br /> Additional information or coamnts: <br /> 2. WATER SUPFLY <br /> IQ water supplied by private well: Yes _ Ilo Is well proper: Yee NO <br /> State 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 & REIvSE <br /> Licensed acaveryger pick-up: Yes _ No _'Service Area No. <br /> Other proposed disposal method : <br /> Potential problem: <br /> 4. FIT, Z10SQUITO OR VECTOR IOUNTIAL <br /> State possible vector potential & necessary control: <br /> S. AIR POLLUTIG:: i'OTc 11'IAI. i <br /> Mate posslo_c burnant: or Nroces;,lii6 {.ullutants 6 necessary control : <br /> 6. MILET/HATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> b. GE1,El(AL iAl,i iATIufJ <br /> :;tato achy problems nut �,ievrou ,ly nu:. .i ; <br /> 9. )PULATION DENSITY <br /> Appx . ,Jo. 1,eople per sq. mi. <br />