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- 1 <br /> (2) <br /> 1. SEWAGE <br /> Distance to Public Sewers �� Connection necessary: Yes _ No _ <br /> Does existing septic system comply with Ord. x{549: Yes _ No � Unknown _ <br /> If no, .ei p-lain:-_­- <br /> Describe septic installation to be installed: .•l <br /> r <br /> Additional information or comments: y <br /> 2. WATER SUPPLY j <br /> I0=,"ttd a supplied'.by private well: Yes _ Ho 1- Is well proper: Yes Ho <br /> S,t�eeficiency: <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 & RM SE <br /> Licensed 'scavenge-r 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 /> $. AIR POLLUTIOLN POMITIAL <br /> State possible burning or processing pollutants & necessary control: <br /> .6,-.,; :TOILET/BATH FACILITIES <br /> ho.t& location existing: Additional facilities need-ad <br /> 7. ?RF-VIOU5 01'EicATION HISTORY <br /> r <br /> 8. CF.IvERAL SANITATION i <br /> State any problems not previously noted: Y� _ <br /> POPULATION `,DENSITY <br /> Appx.. No. People per sq. mi. <br />