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( 1 <br /> 1 . :;L'WAGE I / ^ <br /> Distance to Public Sewers Connection. necessary: Yest/Ivo <br /> Does existing septic system comply with Ord . #51:9: Yes _ No Unknown � <br /> If no, explain: <br /> Ll s a ationnn to be i�n77stalled: <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes _ No _✓mss well proper: Yes _ No <br /> State deficiency: <br /> Does existing or proposed use make this well public water: Yes _ No <br /> Sample of well water taken: Yes _ No _�to Taken Results <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE //j <br /> Licensed scavenger pick-up: Yes _ No _ Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5. AIR POLLUTION POTENTIAL <br /> State possible burning or processing pollutants & necessary control: 11(l6 <br /> 6. TOILET/BATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. PREVIOUS OPERATION HISTORY <br /> b. GENERAL SANITATION <br /> State any problems not previously noted : <br /> r <br /> 9. IOPULATION DENSITY <br /> Appx. Wo. People per sq. mi. <br />