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1. SEWAGE <br /> Distance to Public Sewers , <br /> �/� �` '. Connection rnecessary: i Yes No <br /> Does existing septic system comply t}� 0�. <br /> If no, explain: N�49: Yes• ...`. No Unkno n <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> Is water supplied by private wall: <br /> State deficiency:,` oy Yes No Is well proper:' Yes _ No �M <br /> Does existing or proposed use make this Well public water: <br /> Sample of well water taken: yes Yes No <br /> ,_ No � Date Taken Results • <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes <br /> Other proposed dis NO — Service Area No. <br /> teal. method: <br /> Potential problem: <br /> 4. FLY MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector <br /> Potential & necessary control: �� •- <br /> 5• AIR PO LLU TION PO TEN TIAL <br /> State possible burning or processing pollutants & necessary control: �✓o� • <br /> 6• mILciT/RATH FACILITIES <br /> No. & location existing: ' <br /> Additional facilities needed <br /> 7. PREVIOUS OPERATION HISTORY <br /> r <br /> o• GENT AL SANITATIO11 <br /> State any problems not previously noted: <br /> 9. FOPULATIO14 DENSITY <br /> Appx. ido. People per sq. mi. EIi�E�/y.l <br />