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1. SEWAGE <br /> Distance to Public Sewers n Connection necessary: ; Yes _ No _ <br /> Does existing septic system comply with Ord. N5u9: 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 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: 17 �"u) � <br /> 3. GARBAGE & REFUSES , <br /> Licensed scavenger pick-up: Yes _ No _ Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR VECTOR POMMAL <br /> State possible vector potential & necessary control: <br /> 5. AIR POLLUTION PO TEN TIAL - <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 HISTORY <br /> de- <br /> cs. GENERAL SANITATION <br /> State any problems not previously noted: <br /> 9. FOPULATION DENSITY <br /> Appx. No. People per sq. mi. <br />