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1. SEWAGE °� ( 2) + ' <br />Distance to Public Sewers /r B Connection necessary: Yes _ No <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 <br />Is water supplied by private well: Yes _ No _ Is well proper: Yes _ No _ <br />State deficiency: <br />3. <br />Does existing or proposed use make this well public water: <br />Sample of well water taken: Yes _ No _ Date Taken _ <br />Additional information or comments: <br />GARBAGE & REFUSE <br />Licensed scavenger pick-up: Yes No _ Service Area No. <br />Other proposed disposal method: <br />Potential problem: <br />FLY, MOSQUITO OR VECTOR POTENTIAL <br />State possible vector potential & necessary control: //�1J�1Lj <br />Yes _ No <br />Results <br />5• AIR POLLUTION POTENTIAL <br />State possible burning or processing pollutants & necessary control: /fJe <br />6. TOILET/BATH FACILITIES <br />No. & location existing: Additional facilities needed <br />7. PREVIOUS PREVIOUS OP' TION HISTORYTION HISTORY <br />b. GENERAL SANITATION <br />State any problems not.previously noted: <br />9• POPULATION DENSITY <br />Appx. No. People per sq, mi. ,G <br />