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1. SEWAGE t?) <br /> Distance to j,,ublte Severe Connection necessary: Yes _ No V/ <br /> Does- existing septic eyatan Mp y with Ord. 4549: Yea No Unknown <br /> if no, explSL n: <br /> �. — — <br /> :o- fro <br /> Describe septic'.installation to be installed: a� <br /> Additional information or comments: <br /> 2. WAR SUPPLY Ir <br /> Iq 'vater supplied by private well: Yes Ho — Is well proper: Yes No <br /> S.tgte 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 _ �+ <br /> Licensed scavenger pick-up: Yes _ No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY; MOSQUIM OR TECIOR F0TENTIAL <br /> State possible vector potential & necessary control: <br /> 5. AIR POLLUTION POTEIJTIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILET/BATH FACILITIES <br /> No. & location existing: � Additional facilities needed <br /> 7. i'F&.VIOUS 01-LhATIO14 HISTURY <br /> 8. GEIrERAL SANITATION <br /> State any problems noL previously no;..-d: <br /> 9. POPULATION DENSITY <br /> Appx. No. people per sq. mi. <br />