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(2) <br /> i. SLtidAGr: <br /> Distance to i'ublic Sewers Connection necessary: Yes _ I10 _ <br /> Does existing septic system comply with Ord . d :19: Yes No Unknown <br /> If no, explain: _ <br /> Describe septic installation to be installed: <br /> Additional information or couunents: <br /> 2. WATER SUPFLY <br /> Is water supplied by private well: Yes _ Igo Is well proper: Yes _ No _ <br /> State deficiency: <br /> Does existing or proposed use make this well public water: Yes _ 140 <br /> Sample of well water taken: Yes _ No _ Date Taken Results <br /> Additional information or comments: <br /> 3. GARBAGE & kI•MJ SE <br /> Licensed scavenger pick-up: Yes _ No _ Service Area No. <br /> Other proposed disposal method : <br /> Fotential problem: <br /> 4. FLY, MOSQUITO OR VECTOR I-OMENTIAL <br /> State possible vector potential & necessary control: <br /> S. AIR POLLUTION POTENTIAL <br /> State possible burning; or processing pollutants & necessary control: <br /> 6. 'IUILET/BATH FACILITIES <br /> l+o. & location existing: Additional facilities needed <br /> 7. iItc;VIOUS 01,L ATION HIS'MHY <br /> 6. GEN=ERAL SANTiTATION <br /> State any problems not previc)u;;ly no L_,, : <br /> 9. FOPULATION DENSITY <br /> Appx, No . People per sq. r:i . <br />