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1. SEWAGE <br /> Distance to Public Sewers IAIaAle <br /> Connection necessary: iYes _ NoL�_ Jr <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 T c • A. <br /> >., l <br /> 2. WATER SUPPLY L40 T, -..r <br /> Is water supplied by private well: Yes No _ Is well proper: Yes No <br /> State deficiency: <br /> Does existing or proposed use make this well public water: Yes No s <br /> Sample of well water taken: Yes — No ✓Date Taken Results <br /> Additional information or commentsj�- t?� e ✓ � ' /- /':�c. <br /> 3. GARDAGE & REFUSE �' /' ' Za,T <br /> Licensed scavenger pick-up: Yes — No _ Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FC-Y, MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: — <br /> 5. AIR POLLUTION POTE14TIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILET/SATI{ FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. PREM US OPERATION HISTORY . <br /> 777 1., C_. t . r i # ' .41 <br /> d. GENTRAL SANITATIO14 <br /> State any problems not previously no ted: <br /> 9. IOPULATIO14 DENSITY <br /> Appx, No. People per sq. mi. <br /> 00 <br /> f <br /> 7' <br />