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c 2) 4' <br /> 1. �LwAc;G , <br /> Distance to i'ublic SewersJ <br /> Gf6Se Connection necessary: Yes/—,( No _ <br /> Does existing septic system comply with Ord. d"t19: Yes No Unknown <br /> If no, explain: — — <br /> �0S A�I t c J-e�-,f- <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER Sueny <br /> Is water supplied by private well: Yes _ i-joIs well proper: Yes No <br /> State deficiency: <br /> t.� , <br /> Does existing or proposed use make this weil public water: Yes 1,40 <br /> Sample of well water taken: Yes — No Date Taken Results- <br /> - —_ <br /> Additional information or comments: <br /> 3. GARBAGE & RapSE <br /> Licensed scavenger pick-up: Yes _ No Service Area No. <br /> Other proposed disposal method- <br /> Potential problem: w <br /> FLY, MOSQUITO' OR. VECMR I.OTENTIAL <br /> State possible vector potential & necessary control: <br /> 5• AIR POLLUTIOId POMITIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. IUILGT/BATH FACILITIES <br /> No. & location existing: Additional facilities ueedea <br /> 7. 11LEVIOUS U1• i%A'PIO14 HISIORY <br /> C <br /> ts. GENERAL 3A1dITATIOi4 <br /> State any problems not pruviou ;ly no ,.J: <br /> 9. POPULATION DENSITY — <br /> Appx. Wo. People per sq. n,i. <br /> s <br />