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1. SEWAGE (21 <br /> Distance to Public Sewers Connection necessary: Yes 1/ No .� <br /> Does existing septic system comply with Ord. #549: Yes _ No _ Unknown _ <br /> If no, explain: <br /> Describe septic installation to be installed: <br /> Addit' al information or comments: Q <br /> -� 1 r' o-/ '� - <br /> 2. TER 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: / '-v "k H C , V-'L_ - <br /> 3. GARBAGE & REFUSE Y__e -cam ,di sr <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 /> 5. AIR POLLUTION POTE14TIAL <br /> State possible burning or processing pollutants & necessary control: c1 <br /> 6. TOILET/BATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. PREVIOUS OPERATION HISTORY <br /> 6. GENERAL SANITATION <br /> State any problems not previously noted: <br /> 9• POPULATION DENSITY / <br /> Appx. No. People per sq. mi. <br />