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1. SEWAGE <br /> Distance to Public Sewers ,�, Connection necessary: iYes 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: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes No _ Is well proper: Yes _ No <br /> State deficiency: <br /> Does existingor roposed use make this well public water: Yes Nom <br /> Sample of well wat taken: Yes _ No Date Taken Results <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE <br /> Licensed sca er pick-up: Yes _ No Service Area No. <br /> Other proposed %sposal method: <br /> J <br /> 4. FLY MOSQUITO ORR POTENTIAL <br /> State possible vector tential & necessary control: <br /> 5. AIR POLLUTION POTENTIAL <br /> State possible burning or pro essing pollutis & necessary control: <br /> 6. TOILET/BATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. PREVIOUS OPERATION HISTORY . <br /> GENERAL SANITATIO[d <br /> State any problems not previously noted: <br /> 9. POPULATION DENSITY <br /> Appx, ido. People per sq. mi. <br />