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1. SEWAGE (2) <br /> Distance to Public Sewers _/2 _ Connection necessary: Yes _ No ' 1b <br /> Does existing septic system comply with Ord. #549: Yes No Unknown <br /> If no, explain: — — —' <br /> Describe septic installation to be installed: „ Q <br /> t <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> Is water supplied by private weld: Yes 2_< NO _ Is well proper: Yes _ No <br /> State deficiency: <br /> Does_existin or proposed use make this well public water: Yes X No _ <br /> Sample of well water taken: Yes s No X Date Taken Results <br /> Additional information or comments: <br /> 3. GARBAGE & REEU SE <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 possi e vector potential & necessary control: <br /> 5. AIR PO LLU TIO14 PO TEN TIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILET/BATH FACILITIES <br /> No. & location existing: �� � l/ 1Additional acilities needed <br /> 7. t REVIOUS OPERATION HISTORY <br /> b. GE14ERAL SANITATION <br /> State any problems not previously noted: <br /> 9. POPULATION DENSITY <br /> Appx. No. People per sq. mi. <br />