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1. ' WAOE <br /> Distance to :'ublic Sewers J , <br /> Doea axis i Coar�ec tion neceaeary: Yea No z---- <br /> if <br /> sepyia goteat=r nth Ord. ,��49: Yes No U � <br /> It iw, -explain:' _. <br /> Uascribe antic installation to be installed: <br /> Additional intonation or coam:enta: <br /> 2- WATER SUPFLY <br /> IQ water supplied by private well: Yes <br /> State daticiericy: IIo Ie wall proper: Yee T No <br /> Does existing or proposed use Rake this well public water: Yea No <br /> Sample of well water taken: Yrs _ No <br /> Date Taken Results <br /> Additional information or comments: <br /> 3- GARBAGE & RFkU SE <br /> Licensed scavenger pick-up: Yes _ No 'Service Area No. <br /> Other proposed disposal method: <br /> Fotential problem: <br /> 4• FLT, MOS—WIM OR VECTOR F-OUNTIAL <br /> State possible vector potential & necessary control: <br /> S. AIR I'OLLUTIG:: "OMITIAI. <br /> a La Le posslu--c burnlnt: oz- proccs;,in6 I,ulluLanLs G ncce:ssary control: <br /> 6. FILET BATH FACILITIES <br /> NO. & location exi9ting: <br /> Additional facUlt103 needed <br /> 7. <br /> :;La Lu arty problems nu L j.rcv lou:,ly <br /> 9. OPULATION DENSITY <br /> Appx. i40. I-eople per sq. n4i . <br />