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1. SEWAGE k`) <br /> Distance to Public Sewers Connection necessary: iYes No _ <br /> Does existing septic system comply with Ord. #549: Yes No Unknown <br /> If no, explain: -- '— <br /> AL <br /> Describe septic installation to be installed: -� <br /> 4- <br /> 1 " <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes _ No')v 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 prop ed disposal method: <br /> Potential pro em: <br /> 4. FLY MOSQUITO 0 VECTOR POTENTIAL <br /> State possible vec potential & necessary contr <br /> 5. AIR PO LLU TION PO TEI1 TIAL <br /> State possible burning or process pollutants & necessary control: <br /> 6. TOILET/LATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. PREVIOUS OPERATION HISTORY . <br /> 6. <br /> GENT-,RAL SAIIITATIO1/not <br /> State any problempreviously noted : <br /> f <br /> 9. POPULATION LNSITY <br /> Appx. No. 1eople per sq. mi. <br />