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1. SEWAGE <br /> (2) <br /> Distance to i'ublic Sewers Connection necessary: Yes _ No _ <br /> Does existing aeptic system comply with Ord. WJ 49: Yes No Unknown <br /> if no., ezplain:­ _ _ <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> I0 water supplied by private well: Yes _ 110 _ Is well proper: Yes No _ <br /> S,t$te deficiency: T <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 /> 3. GARBAGE & REkAJ SE <br /> Licenseds--avenger pick-up: Yes _ No _ Service Area No. <br /> Other proposed disposal method : <br /> Potential problem: <br /> Lt. FLY, MOSQUITO OR VECTOR F-0TENTIAL <br /> State possible vector potential & necessary control: <br /> S. AIR POLLUTION POTENTIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. 1UI1ZT/BATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. IIHEVIOUS oi,i;i-cA'rION HIS`Jti1tY <br /> �. GENERAL SAN11TATIO14 <br /> State any problems not previously no-, : <br /> 9. POPULATION DENSITY <br /> Appx. No. People per sq. mi. <br />