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\moi <br /> 1. SEWAGE <br /> Distance to Public Sewers ,�,��, Connection necessary: Yes _ No <br /> Does existing septic system comply with Ord. #549: Yes No Unknown <br /> If no, explain: <br /> 4 <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> Is 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 / <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 /> .✓cid <br /> e- <br /> 5. <br /> - <br /> 5. AIR. PO LLU TION PO M4 TIAL <br /> State possible burning or processing pollutants & necessary control: <br /> e a-� -I-X is s4a X . <br /> 6. M ILET/BATH FACILITIES 61 <br /> No. & location existing: {� _ Additional facilities needed <br /> 7. PREVIOUS OPERATION HISMRY . <br /> LIh a✓C? G c r,� :, l�,> >.. L' � -� %c Gt li ti q lu T <br /> 8. GENERAL SA14ITATION <br /> State any problems not previously noted: <br /> /"e'YI e- <br /> 9. FOPULATION DENSITY <br /> Appx, No. People per sq. mi. <br />