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1 <br /> 1 . Si�JAGE I 1� <br /> Distance to Public Sewers Connection necessary: Yes _ No <br /> Does existing septic system comply with Ord. #5149: 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 _ No <br /> State deficiency: <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 & REFUSE <br /> Licensed scavenger pick-up: Yes _ No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> L. FLY, MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5. AIR POLLUTION POTENTIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILET BATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. PREVIOUS OPERATION HISTORY <br /> - 1 <br /> b. ENERAL S NITATION <br /> State any problems not previously noted: <br /> 9• IOPULATION DENSITY - <br /> Appx. No. People per sq. mi. <br />