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1. SEWAGE <br /> Distance to Public Sewers f'% Connection necessary: iYes _ No <br /> Does existing septic system comply with Ord. #')49: Yes. No Unknown <br /> If no, explain: 1 <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> Is Water supplied by privato well: Yes No Is well proper: Yes No <br /> State deficiency: lr/� eG �5l' E�,,O J-� �j <br /> w,. <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 <br /> Licensed scavenger pick-up: Yes _ No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSQUIM OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> S. AIR POLLUTION POMITIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. M ILET/BATH FACILITIES / <br /> No. & location existing; /✓f Additional facilities needed _ <br /> 7. PREVIOUS OPERATION HISMRY . r <br /> o. GENERAL SANITATIO14 <br /> State any problems not previously noted: <br /> 9. POPULATION DENSITY <br /> Appx, No. People per sq. mi. <br />