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1. SEWAGE <br /> Distance to i'ublic Sewers Connection necessary: Yes _ No <br /> Does. existing septic system oom—pTy with Ord. , 549: Yea No Unknown <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER SUPFLY <br /> I water supplied by private well: Yes NO Is well proper: Yes No <br /> S.t4te 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 & Rl�n SE <br /> Licensed scavenger pick-up: Yes _ No _ Service Area No. <br /> Other proposed disposal method : <br /> Potential problem: <br /> 1:. FLY; MOSQUITO OR VECTOR 10TENTIAL <br /> State possible vector potential & necessary control: <br /> 5. AIR PO LLU TION PO TEN TI A L <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILET/BATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. i'REVIOU5 01'C nATI01J HISTORY <br /> o. GENERAL SAI;ITATIO14 <br /> State any problems not previously noz,d : <br /> 9. POPULATION DENSITY <br /> Appx. No. People per sq. mi. <br />