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1. SEWAGE <br /> Distance to Public Sewers Connection necessary: YesNo` ► <br /> Does existing septic system comply with Ord. #549: Yes 1 '-7- <br /> No Unknown <br /> IX_no_,-explain: ; y& O 5 A' w.tr `�� 0" — — <br /> 1 % /� �� 7� <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> i <br /> 2. WATER SUPPLY 7q <br /> Is water supplied by private well: Yes �No _ Is well proper: Yes No <br /> St."�—ency: i ) o <br /> Does existing or proposed use make this well public water: Yes _ No j._ ¢ " <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 /> u. 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. PREVIO S OPERATION HISTORY . <br /> r � <br /> ly <br /> r <br /> GENERAL SANITATION <br /> State any problems not previously noted: <br /> 9. POPULATION DENSITY <br /> Appx. No. People per sq. mi. <br />