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1. SEWAGE <br /> Distance to Public Sewers Conne ion-necessary: Yes —_N 0_ _ <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 4---No Is well roper es _ No _ <br /> St�e-d•� ency: `> <br /> proposed use make this well public water: Yes I/No <br /> Sample of well water taken: Yes No 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 /> Potentia]. problem: _ <br /> !�. FLY, MOSQUITO 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. PREVTOM5 OPERATION UISTORY . <br /> /t <br /> e_ <br /> 8. GENERAL SANITATION <br /> State any problems not previously noted: <br /> 9• POPULATION DENSITY <br /> Appx, No. People per sq. mi. <br /> dA/ -c. k i 5 f <br /> UT�rJy1�P/L /�z 5 5�1 8 /y <br /> ���-• � ,� �,1�/ � � � � �'S �-ley. <br />