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1. SEWAGE <br /> Distance to Public Sewers _ Connection necessary: Yes_ No - <br /> Does existing septic system comply with Ord. #5h9: Yes _ No Unknown _ <br /> If no, explain: <br /> Describe septic installation to be installed: <br /> Additional information or comments: e) r- Y' <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes No _ Is well proper: Yes _ No <br /> Staff djoficiency: LV'y' i !,, C4, _&^,i 1,e <br /> ! rem <br /> Does existing or proposed use make this well public water: Yes _ No <br /> Sample of well water taken: Yes _ No _ Date Taken Results <br /> Additional information or comments: o Q X_'__ <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 PO LLU TION PO MMAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILET/BATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. PREVIOUS OPERATION HISTORY . <br /> 6. GENERAL SA14ITATIO14 <br /> State any problems not previously noted: <br /> 9. FOPULATIO14 DENSITY <br /> Appx. No. People per sq. mi. <br />