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1 . JLvrAGE k/A_ <br /> Distance to i'ublic oewers Connection necessary: Yes i.o _ <br /> Does existing septic system comply with Ord. x#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 water supplied by private well: Yes _ No ` Is well proper: Yes _ No <br /> State deficiency: <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 & REFUSE ti1d4-- <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 POLLUTION PO TEN TIAL I✓/j'�-_ <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 /> 8. GE14ERAL SANITATION ("J( <br /> State any problems not previously noted: <br /> 9. POPULATION DENSITY <br /> Appx. No. People per sq. mi. <br />