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0 <br />(2) <br />1. JLMAGti <br />Distance to i'ublic Sewers Connection necessary: Yes _ Ido <br />Does existing septic system comply with Ord. W'54:9: Yes _ No _ Unknown <br />If no, explain: <br />Describe septic installation to be installed: <br />Additional information or comments: <br />2. WATER SUPPLY <br />Is water supplied by private well: Yes _ NO _ Is well proper: Yes _ PJo <br />State deficiency: <br />3. <br />4. <br />Does existing or proposed use make this well public water: Yes _ No <br />Sample of well water taken: Yes _ No _ Date Taken Results` <br />Additional information or comments: <br />GARBAGE & REFUSE <br />Licensed scavenger pick-up: Yes _ No _ Service Area No. <br />Other proposed disposal method: <br />Potential problem: <br />FLY, MOSQUIT6 OR. VECTOR 1-OTE:NTIAL <br />State possible vector potential & necessary control: <br />S. A4R POLLUTION POTEIJTIAL <br />State possible burning or processing pollutants & necessary control: <br />6. TOILET/BATH FACILITIES <br />No. & location existing: <br />7. "REVIOUS 01'LitATIOI4 HISTORY <br />6. GENERAL SAVITATION <br />State any problems not previously not�.i: <br />9. POPULATION DENSITY <br />Appx. No. People per sq. nii. <br />Additional facilities needed <br />