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1. SEWAGE �, <br /> Dista G < �2. <br /> Distance to Public Sewers <br /> Does existing septic Connection necessary: iYes No <br /> If no, explain: system comply with Ord. 1/j49: Yes• .!. No _ Unknown <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER SUPPLY - <br /> Is water supplied by private wolf: Yes `al f-� <br /> S to is-amici enc NO Is well proper per: Yes No <br /> Does existing or pro C)posed use make this well public water: Yes <br /> Sample of well water taken: Yes ._ No Date TakenNo <br /> Results ' °'" <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE <br /> Licensed scavenger. pick-up:p: Yes _ No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY MOSQUIM OR VECTOR PLMTIAL <br /> State possible vector <br /> Potential & necessary control: ___ •- <br /> S. 11M POLLUTION POTENTIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6• mILET/BATH FACILITIES <br /> No. & location existing: <br /> HISTORY Additional facilities needed <br /> 7. PREVIOUS OPERATION <br /> r � . <br /> 8-• GENERAL SANITATIOIJ <br /> State any problems not previously noted: <br /> 9. FOPUTATIO14 DENSITY <br /> Appx. 140. People per sq. mi. <br />