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1. S&i AGE (2) <br /> Distance to Public Sewers Connection necessary: Yes _ No _'(�_ <br /> Does existing septic system comply with Ord. #549: Yes _L No Unknown <br /> If no, explain: — '— <br /> Describe septic inst llation to be installed: 0 L t <br /> �Q -d Th, doz- <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes L 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 zService Area No. <br /> Other proposed disposal method: 4_�Pt <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5. AIR PO LLU TION PO TEN TIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILET/BATH FACILITIES <br /> No. & location existing: j�QSL� Additional facilities needed. <br /> 7. P EVIOUS OPERATION HISIC7RY ` <br /> e <br /> 8. GENERAL SANITATIO14 <br /> State any problems not previously noted: <br /> 9. POPULATION DENSITY <br /> Appx. No. People per sq. mi. <br /> EH 06 o6 3/71 <br /> 4/74 750 <br /> 0- <br />