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1. SEWAGE (2) <br /> jam_ <br /> Distance to Public Sewers " Connection necessary: Ye�A_ No _ <br /> Does existing septic system comply with Ord. #549: Yes _ No _ Unknown <br /> If no, explain: <br /> Describe septic installation to be installed: / .� (y 4C„_ -7k 6 <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 _ Noy Date Taken Results <br /> Additional information or comments: C ne c�,11I� �u �, ( !ti "I t'i _A_1(19/1 l,, c�- <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: <br /> 5. AIR POLLUTION POTENTIAL <br /> State /Ipossible burning or processing pollutants & necessary control: <br /> INS bJr/�i►�5 I ILG ✓JJ Vrn[ <br /> 6. TOILET/BATH FACILITIES k�� <br /> No. & location existing: Additional facilities needed <br /> 7. PREVIOUS OPERATION HISTORY <br /> 8. GENERAL SANITATION <br /> State any problems not previously noted: <br /> 9. POPULATION DENSITY <br /> Appx. No. People per sq. mi. <br />