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1. SEWAGE <br /> Distance to Public Sewers Connection necessary: YesNo <br /> -7Does existing septic system comply with Ord. #5h9: Yes. No Unknown <br /> If no, explain: <br /> D cribe septic-=talration totoe Al d <br /> be`ir to ezJ: 7',�i D �.r J,Or1aS �' <br /> " <br /> Additional information or comments: <br /> WATER SUPPLY �va -7-;oO�/ G�'� Lva ��' (,tJ Gr M, t) / G{� <br /> F Is water supplied by private well: Yes _vNo 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 Date Taken Results <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE <br /> Licensed 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 PO LLU TION PO TEN TIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILET/HATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. PREVIOUS OPERATION HISTORY . <br /> GEN AL SANITATIO11 <br /> State any problems not previously noted: <br /> 9. POPULATION DENSITY <br /> Appx, No. People per sq. mi. <br /> ral op .61 ee�—' <br /> r <br />