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1 , <br /> 77v <br /> Distance to Public Sewers �f- knnection necessary: Yes _ ho _ <br /> Does existing septic system comply with Ord . #5149: Yes <br /> If no, explain: <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WA'T'ER SUPPLY <br /> Is water supplied by private well: Yes _ No i_�Is well proper: Yes <br /> State deficiency: is!- J <br /> Does existing or proposed use make this well public water: Yes ' --_ <br /> Sample of well water taken: Yes _ No L—Date Taken <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes _ No _V!ervice Area No. b fes- l �5y <br /> Other proposed disposal method: <br /> I✓otential problem: <br /> 4. FLY, MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5. AIR POLLUTION POTENTIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILET/BATH FACILITIES � '� <br /> No. & location existing: "'" ddi�facilities needed <br /> 7. PREVIOUS OPERATIO14 HISTORY <br /> vr" <br /> b. GENERAL SA141TATIO14 <br /> State any problems not previously noted: <br /> 9. I-OPULATION DENSITY <br /> Appx. No. People per sq, mi. <br />