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1. SEWAGE k10 <br /> Distance to Public Sewers Connection necessary: Yes No k;' ' <br /> Does existing septic system comply with Ord. #549: Yes. No 1hA own . <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 existing or proposed use make this well public water: Yes No <br /> Sample of well water taken: Yes _ No L Date Taken Results <br /> Additional information or comments: <br /> 3. GARDAGE & REFUSE- <br /> Licensed <br /> EFUSELicensed 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 POLLUTION POTENTIAL <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 STORY . <br /> o. GENTRAL SANITATION <br /> State any problems not previo noted: <br /> 9. FOPULATION DENSITY <br /> Appx. No. People pe sq. mi. <br />