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1. SEWAGE (2) <br /> Distance to Public Sewers �D/� 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: S , <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes &/'IJo Is well proper: Yes No _ <br /> State deficiency: _z�N <br /> Does existing or proposed use make this well public water: Yes _ No a� <br /> Sample of well water taken: Yes _ No "J Date Taken Results <br /> Additional information or comments: .T <br /> 3. GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes _ No _ Service Area No. 72� S�/ �. <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 PO LLU TION PO TEN TIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILET/BATH FACILITIES <br /> No. & location existing: A/11_� " 4 Additional facilities needed <br /> 7. ?REVIOUS OPERATION HISTORY <br /> b. GENERAL SANITATION <br /> State any problems not previously noted : �`r'-y/i� <br /> 9. POPULATION DENSITY <br /> Appx. No. People per sq. mi. <br />