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1. SEWAGE . <br /> Distance to Public Sewers Connection necessary: Yes No _ <br /> Does existing septic system comply with Ord, #'49: Yes. No Unknown <br /> If no, explain: _ <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes No Is 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 _ Date Taken _ Results <br /> Additional information or comments: <br /> 3• GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes _ No Service Area No. <br /> Other proposed disposal method: <br /> 4. FLY, MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> S. AIR PO LLU TION PO TEN TIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILET/HATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. PREVIOUS OPERATION HISTORY , r <br /> d. GENT AL SANITATIOIJ <br /> State any problems not previously noted: <br /> 9. FOPULATION DENSITY <br /> Appx. No. People per sq, mi. <br />