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1 :;EW A GE <br /> 7 I <br /> Distance to i'ublic J'ewers `' r� Connection necessary: Yes _ I;o <br /> Does existing septic system comply with Ord. #519: Yes ,„ _ Iwo 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: ro­ <br /> Does <br /> existing or proposed use make this well public water: Yes _ No +_ <br /> Sample of well water taken: Yes No I' Date Taken -- �esZts <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes _No Service Area No. Lod <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 POLLUTION PO TEN TIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILET/BATH FACILITIES <br /> No. & location existing: � Additional facilities needed i <br /> 7. PREVIOUS OPERATION HISTORY <br /> 8. GENERAL SANITATION <br /> State any problems not previously noted: <br /> 9. POPULATION DENSITY <br /> Appx. No. People per sq. mi. Q `' <br />