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w <br /> 1. SEMAGE �'�?�rU U P i (2 <br /> Distance to Public Sewers 00-- rConne$tion necessary Yes e _\.,/Ido' _ <br /> Does existing septic system comply with Ord. #549: Yes No Unknown <br /> If no, explain: <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER SUPPLY D C <br /> Is water supplied by private well: Yes lio e Is well proper: Yes NO <br /> State deficiency: <br /> Does existing or proposed use make this well public water: Yes` 1110 _ <br /> Sample of well water taken: Yes Na '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: C vA0 S 06 Sc <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR VECTOR I-OTENTIAL / <br /> State possible vector potential & necessary control: n <br /> 5. AIR PO LLU TION PO TEN TIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. 'FILET/BATH FACILITIES �) <br /> No. & location existing: /" � Additional facilities needed <br /> 7. ?hEVIOUS 01,L tATIO HISTORY <br /> 8. GEI,�J1RAL SANITATION <br /> State any problems not previously noted: �o(Le, <br /> 9. POPULATION DENSITY /IiAi <br /> Appx No. People per sq. mi. tJ Cam Cf <br /> ( 6 <br />