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1. JLMAGE(2) <br />Distance to Vublic Sewers r Connection necessary: Yes_ No <br />Does existing septic system comply with Ord. W`i119: Yes No Unknown <br />If no, explain: — _ <br />Describe septic installation to be installed: I - <br />Additional information or comments: <br />2. NATER SUBTLY <br />Is water supplied by private wall: Yes <br />NO _ Is well proper: Yes No <br />State deficiency: <br />Does existing or proposed use make this well public water: Yes _ 1,40 <br />Sample of well water taken: Yes _ No Date Taken <br />Results _ <br />Additional information or comments: <br />3. GARBAGE & REFUSE <br />Licensed scavenger pick-up: Yes _ No <br />Other proposed disposal method; _ Service Area No. <br />Fotential problem: <br />!�. FLY MOSQUITO OR V'EC'TOR I OTr MAL <br />State possible vector potential & necessary control: <br />5. AIR POLLUTION POTEIIT'IAL <br />State possible burning or processing pollutants & necessary control: <br />b. 'M ILET/BATH FACILITIES <br />I'o. & location existing: <br />Additional facilities ueedea <br />7. .'•hr;VIU�Uj 01. tpriw III,IUIiY <br />b. GCI:ERAL SANITATI0N <br />State any problems not previoUc;iy no ;.%.,j <br />9. FOPULATIUN DcNSI'rY <br />Appx. lo. People per :;q. <br />