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5 <br /> l. :ii✓WAcI� <br /> Distance to Vublic Sewers Connection: necessary: Yes. No <br /> Does �., ._.,. . . <br /> existing aeptila ayatea �y with Ord: ,�5h4: Yes Ho IJNcno+m i <br /> Describe <br /> .naptic inatallatian tobe,inat►aledzj J. ` <br /> Additional infortmtion.or coamenta: . <br /> 00/ or <br /> 2. wATER SUPPLY <br /> Iq eater supplied,by privato well: Yes J F,O _ Ia well proper: 'lee Na _ <br /> 314te deficieAcy: T <br /> i • <br /> Does existing or proposed use make this well public water: Yea _ No L_ _ <br /> Sample of well water taken: Yes No -''Date Taken Resulta--" <br /> Additional informratioa or comments: <br /> 3. GARBAGE & Rl asE C4 NA-,-V tz)64,F a f- -i- /r, <br /> Licensed+acavenger puck-up: Yes No 'Service Area No. <br /> Other proposed disposal method:-' <br /> Potential problem: <br /> L. FLY MOSQUITO OR VECTOR i- MTIAL <br /> State possible vector potential & necessary control: <br /> 5. ATR I'OLLUTIG:: i'OTcIlTlki, - - <br /> tw :iLatn posslo_L bur rune or procc:�;-iiib I,o11uLanLs & necessary control: /V 6 <br /> 6. JulL ,T BA-M FACILITIES ` <br /> I"0- & location existing: Additional facilities needed <br /> rF ?. <br /> GEN' :l{A L jkK i 7A TION <br /> "tat() atLy problems tjut E,j,eviou:,iy ,1u _ is <br /> j9. POPULATION � <br /> APpxG�ople per sq. 041. .��, <br />