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(2) " <br /> 1. StUAGE <br /> Distance to i'ublic Sewers Connection necessary: Yes No <br /> Does existing septic system comply with Ord. d549: Yes — No _ Unknown — <br /> It no, -eYplaln:­ <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> Ip'vatet supplied ,by private well: Yes No Is well proper: Yes No <br /> Sti+}te_d`eticiaiicy: <br /> Does existing or proposed use make this well public water: Yes _ No —i <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 I-OTENTLAL <br /> State possible vector potential & necessary control: <br /> S• AIR POLLUTION POTENTIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILET/BATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. ?REVIOUS Oi'inATION HISTORY <br /> b. GENERAL SANITATION <br /> State any problems not previously no,d : <br /> 9. POPULATION DENSITY <br /> Appx. No. People per sq. mi. <br />