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1. SEWAGE ` <br /> Distance to Public Sewers <br /> Does existing septic Connection necessary: i Yes No - <br /> Il no, explain: system comply with Ord. #510: Yes. ` NO _ Unknown <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> Is water suppliod by private well: Yes _ <br /> State deficiency: NO --` Is well proper: Yes No <br /> Does existing or proposed use make this well public water: <br /> Sample of well water taken. Yes .G .. No <br /> Yes _ Ito Date Taken <br /> Additional information or comments: Results <br /> 3. GARBAGE & REFUSE <br /> Licensed scavenger pick-up: yes <br /> Other proposed dis NO Service Area No. <br /> disposal method: <br /> Potential problem: <br /> 4. FLY MOSQUIM OR VECIPH POTENTIAL <br /> State possible vector <br /> Potential & necessary control: <br /> 5• AIIt POLLUTION POTENTIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. 10ILET BATH FACILITIES <br /> No- & location existing: <br /> /V/� <br /> ?. P13EVIOUS OPERATION 1{ISTURY Additional facilities needed <br /> o. GE1�ERAL SANITATI011 <br /> State any problems not previously noted: -� <br /> 9. FOPUTATIO14 DENSITY <br /> Appx. ido. People per sq. mi. <br />