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1. SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No _ <br /> Does existing septic system co:rnply with Ord. #j19: 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 /> Potential problem: <br /> 4. FLY, MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: r ?/YE <br /> 5. AIR PO LLU TION PO TEN TIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILET/BATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. PREVIOUS OPEnA`TO_N IiISTORY . <br /> d. GENTERAL SANITATION <br /> State any problems not previously noted : <br /> 9. FOPULATION DENSITY <br /> Appx. No. People per sq. mi. <br />