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1. SEWAUE (2) <br /> Distance to &'ublic Sewers <br /> Does exis i Comectlon necessary: - Yes No <br /> 4 nN :--- system ry with Ord. J549: Tsa No USM <br /> It nog axplsine' `� _. <br /> z <br /> Describe septic installation to be installed: <br /> Additional information or coxmnts:._._ <br /> ; o ; <br /> 2. WA1EFt $(1PFLY _. <br /> 14 .w . supplied.by_ private well: " Yes ✓/17o Is well proper: Tea NO, <br /> 44" deficiency: -- <br /> Does existing or proposed use make this Well public water: Tea No <br /> Sample .of well water takene"' Yes _ No � Data Taken ~ <br /> Results <br /> Additions'! information or comments: <br /> j. C+ARHAGE � REFUSE <br /> Licensed scavenger ng pick-up: Yes No _'Service Area No. <br /> Other Proposed disposal posal method:' <br /> I=PQ UMI- problem: r <br /> 4- FLT. FfOSQUIIO OR VECIUR i0h7rTIAL <br /> State possible vector potential & necessary control: _ <br /> S. AIR POLWTIG:. i'OTEIITIAL <br /> estate possr U:e bur.nlnU. or processuig I#U11ut3nt5 6 necessary control: <br /> 6. TOILET/RATN FACILITIES <br /> ho. & location existing: Additional facilities needed <br /> 7. rI r:V1UU:; <br /> b. GEI,ERAL SAKI7ATIUII <br /> :i atu arky problems nut jxevroUrly <br /> POPULATION DENSITY <br /> Appx. NO. F'eople per <br />