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1. SEWAGE <br /> Distance to Public Sewers ;. <br /> Connection necessary: Yes _ No � <br /> Does existing septic system comply with Ord. #-r49: <br /> If no, explain: Yes• No Unknown <br /> Describe septic installation to'-be installed: <br /> Additional InXormation or comments: <br /> 2. WATER SUPPLY / <br /> Is water supplied by private well: Yes ✓ No Is well proper: Yes No <br /> State deficiency: _ �� �� _ - � 4? <br /> Does existing or proposed use make this well/public water: Yes _ No <br /> Sample of well water taken: Yes _ 110 -"Date Taken Results <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes — No Service Area No. �A <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: T , ,� <br /> 5. AIR PO LLU TION PO MITIAL <br /> State possible burning or processing pollutants & necessary control: l Q�ti( K.Otn1� <br /> 6. 1nILET BATH FACILITIES <br /> No. & location existing: _ n( Additional facilities needed _. <br /> 7. PREVIOUS OPERATION IIISTORY . r <br /> 0. GEUT3RAL SANITATI0I1 <br /> State any problems not previously noted: <br /> 9. FOPULATIO14 DENSITY <br /> Appx, No. People per sq. mi. <br />