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1. SEWAGE <br /> Distance to Public Sewers a , / <br /> Does existing septic systeConnection necessary: Yes No <br /> m comply with Ord, #549: Yes — — <br /> If no, explain: _ No _ Unknown <br /> - <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER 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: <br /> 3• GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes — No Service Area No. <br /> Other proposed disposal method: X� <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5. AIR POLLUTION POTENTIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. ToilzT/BATH PACILITIGS <br /> No. & location existing: <;Ayiditional facilities needed <br /> 7. PREVIOUS OPERATION HISTORY . <br /> d. GENTMAL SANITATIOIJ <br /> State any problems not previously noted: �y.p."yee' v�u! - py t�f'- tiny y9fd <br /> �i�"�1 <br /> 9. POPULATION DENSITY <br /> Appx. No. People per sq, mi. f✓f�� <br />