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1. SEWAGE , <br /> Distance to Public Sewers ✓iConnection necessary: iYes _ No _ <br /> Does existing septic system comply with Ord, #549: Yes. No Unknown <br /> IS no, explain: <br /> Describe septic installation to be installed: i r <br /> Additional information or comments: <br /> G: <br /> _ �.P i!'c tea/ -y� 4:', ,,,�„�.,�,.. _. <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes No Is well proper: Yes Y" No <br /> State deficiency: <br /> Does existing or proposed use make this well public water: Yes _ No _X/ <br /> Sample of well water taken: Yes _ No 4- Date Taken Results <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes _�L No _ Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSQUIM 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 /> d. GENERAL SANITATION <br /> State any problems not previously noted: <br /> 9. POPULATION DENSITY <br /> Appx. No. People per sq. mi. �/j�C �' �"✓C ✓.�'.�� <br />