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1. SOUA0E ( 2) <br /> Distance to "ub110 Sewers �. <br /> �� Connection necessary: Yea No <br /> Doss exisFing septic gotea oostply with Ord. ,x549: Xes No �D�� <br /> if not 4iP'1sio:' • — — <br /> ���� - � � t'fit'✓�G� (�('��'l.i.G�/'.� ` , �.�i-.,� <br /> Ueacribe adptic installation to be installed: <br /> Additional information or coaasents: <br /> 2. WATER SUPPLY <br /> IQ water supplied by private well: Yes <br /> �o Is well proper: Yee No � <br /> State deficiency: _�' AA. <br /> Does existing or proposed use make this well public water: Yea _ No ✓_ <br /> Sample of well water taken: Yes No _ <br /> / Date Taken _ Rsaulta <br /> Additional information or comments: <br /> 3. GARHACF. & REF�1 SE <br /> Licensed acaverkger pick-up: Yes No .k//"Service Area No. <br /> Other proposed disposal method : <br /> Potential problem: <br /> �- FLT, MOSQUITO OR VECTOR t-O'IENTIAL <br /> State possible vector potential & necessary control: •` `/ <br /> S . AIR POLLUTIG:: r'OT"c119'lAl. <br /> L),LaLepossio_e burrunt: or procussln6 I,ulluLanLs & necessary control : <br /> 6. TOILET/Mn FACILITIES <br /> NO- & location existing: AddiLlonal factlitles needed <br /> 7• <br /> b. (:1•: RAL jAK i iA TION <br /> :i La Lu arty problems nub �x vlou:,ly <br /> 9. POPULATION DENSITY <br /> APPX• iJo. !-eople per sq. n,i . ��.n✓,L� � <br />