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1. E-WA0E (2) - <br /> Distance to 1'ub110 Sewers <br /> - Does exis i Connection nsceseary: Yea No • ` <br /> ` septic gstea o� Frith Ord. 649: Yea mo — Unknow <br /> Describe peptic installation to be installed: <br /> Add <br /> itional inform Lion or oo,mnts: <br /> 2. WA <br /> 4ER-SUPFiY <br /> ater <br /> IQ 'w _ supplied..by private well• Yea >r ` . <br /> Sate deticienc ---�t�o Ie well proper: Yea T too <br /> y: < <br /> Dose existing or proposed use snake thin well public water: Yea - No <br /> Sample of well water taken: Xes No Date Taken Results~ <br /> •. _ <br /> AdditiorLal information or comments: ' <br /> 3. GARUrE k RMSE _ <br /> Licensad scavenger� pick-up: Yes _ No 'Service 11res4(o-,-- <br /> Other proposed disposal method: <br /> Potential problem: <br /> MOSQUI•IO OR IIRCMR I.OMTIAL ---- _- <br /> State possible vector potential necessary control: <br /> S• AI ft I.O LLU TI G:: i'O Tc:U 1'I A 1, i <br /> :31taLe possluze burnin • or <br /> L Nroces:;lu6 l,ullutantS 6 necessary control: <br /> 6. M LET LWM FACILITIES <br /> ho_ & location exi9ting: Additional facilities needed <br /> 7. •lu;vluu:; ui ..-• rIo» 1c1 :l;,�cr <br /> b- GENERAL :iAl:i 7ATIU1j <br /> :i La Lu atky problems nut j,reviou:,ly <br /> POPULATION DENSITY - <br /> APpx. ;Jo. Feople per sq. poi. <br />