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1. SEWAGE <br />2. <br />(2) <br />Is <br />Distance to Public Sewers Connection necessary: Yes _ No _ <br />Does existing septic system comply with Ord. #549: Yes _ No _ Unknown <br />If no, explain: ' <br />Describe septic installation to be installed: <br />Additional information or comments: <br />WATER SUPPLY <br />Is water supplied by private well: <br />State deficiency: <br />Yes No Is well proper: Yes _ 140 <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 />4. <br />Potential problem: <br />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/BATH FACILITIES <br />No. & location existing: Additional facilities needed <br />7. PREVIOUS OPERATION HISTORY <br />8. GE14ERAL SANITATIO14 <br />State any problems not previously noted: <br />9. POPULATION DENSITY <br />Appx. No. People per sq. mi. <br />