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1. SEWAGE <br /> Distance to Public Sewers Connection necessary: lyes <br /> Does existing septic systeNo <br /> m comply with Ord, #569: Yes, No Unknown <br /> If no, explain: — <br /> Describe septic installation to be installed: <br /> Additional�infprmation or comments: <br /> C �id lQ <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes No Is State deficiency: /(� l, L — s wproper:per: Yes ._ No <br /> Does existing or proposed use make this wellwater: Yes ublic <br /> Sample of well water taken: Yes No P — No <br /> — 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 /> 4. FLY, MOSQU24U OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> S. AIR POLLUTION POTENTIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. 70I1ET/BATH FACILITIES <br /> No. & location existing: <br /> Additional facilities needed <br /> 7. PREVIOUS OPERATION 1iIS1URY <br /> o. GENERAL SANITATIOtl <br /> State any problems not previously noted: <br /> 9. POPULATION DENSITY <br /> APPx. No. People per sq. mi. <br />