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1. SEWAGE <br />(2) <br />Distance to Public Sewers Connection necessary: Yes _ No <br />Does existing septic system comply with Ord. d,�49: 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 _ I+o _ Is well proper: Yes No <br />State deficiency: <br />3. <br />4. <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 & DEFUSE <br />Licensed scavenger pick-up: Yes _-No _ Service Area No. <br />Other proposed disposal method: <br />Potential problem: <br />FLY, MOSQUITO OR VECTOR I-OTENTIAL <br />State possible vector potential & necessary control: <br />Yes _ No _ <br />Results <br />rj. AIR POLLUTION POTENTIAL <br />State possible bhrning or processing pollutants & necessary control: <br />6. 'TOILET/BATH FACILITIES <br />No. & location existing: <br />7. PkEVIOUS Ul'LwkTION HISTORY <br />8. GEb'RAL 'SANITATION <br />State any problems not previously noted: <br />9. POPULATIO14 DENSITY <br />Appx. No. People per sq <br />I <br />mi. <br />Additional facilities needed <br />C <br />f <br />