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1. SEWAGE <br /> Distance to Public Sewers / '' Connection necessary: Yes _ No <br /> Does existing septic system comply with Ord. #549: Yes _ No _ Unknown <br /> If no,,ex-plain: 4v <br /> r11V <br /> .," AA <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> Is water supplied bypr'vate well: Yes ✓No Is well p, per: Yes ` No — <br /> $tate_defzc�tency: 2 <br /> &es existing or proposed use make this well public water: Yes _ No <br /> Sample of well water taken: Yes _ No ate Taken Results <br /> Additional information or comments: e � 6t r � <br /> 3. GARBAGE & REFUSE <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 PO TE14TIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILET/BATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. PREVIO S OPERATION HISTORY . <br /> cs. GENERAL SANITATI014 <br /> State any problems not previously noted: <br /> 9. POPULATION DENSITY <br /> Appx, No. People per sq. mi. <br />