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1. SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes _ No ` <br /> Does existing septic system comply with Ord. #549: 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 V1 No _ Is well proper: Yes _ Wo <br /> State deficiency: <br /> Does existing or proposed use make this well public water: Yes _ No Ln— <br /> Sample of well water taken: Yes No Iii 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, MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5. AIR PO LLU TION PO TE14 TIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. MILET/BATH FACILITIES <br /> No. & location existing: ,.r� �.- Additional facilities needed <br /> 7. PREVIOUS OPERATIO14 HISTORY <br /> h. GENERAL SalITATIOI� <br /> o tate any problems not previously noted: <br /> 9. IOI'ULATION DENSITY <br /> Appx. No. People per sq. mi. �a.i <br />