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1. 5EMAGI <br /> Distance to Public Sewers Connection necessary: iYes ` No <br /> Does existing septic system comply with Ord. #'49: 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 z No _ <br /> Sample of well water taken: Yes — No Date Taken Results <br /> Additional information or comments: <br /> 3. GARBAGE & REMOSE <br /> Licensed scavenger pick-up: Yes _ No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> L�. FLY, MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> i <br /> 5. AIR PO I.LU TION PO MI TIAL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILEWBAIN FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. PREVIOUS OPERATION HI7L <br /> STORY , <br /> d. GrNTMAL SANITATION <br /> State any problems not previously noted: <br /> 9. POPULATION DENSITY <br /> Appx. No. People per sq. mi. <br />