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1 . SRWASTL <br /> Distance to Public Sewers Connection necessary: Yes No <br /> Does existing septic system comply with Ord, 0545 : Yes No— <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 2. WATER SUPPLY <br /> Is Water supplied- by private well : Yes No Is well proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water taken: ' Yes No Date taken <br /> Results Additional information or comments <br /> 3 , GARBAGE & FR FUSE <br /> Licensed scavenger pick=up: Yes—, * 'No— Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSQUITO 02 -VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5 . TnILETZBATH FACI E TES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVTOUS OPERAITQN HTSIOUX <br /> 7 . GENERAL SANTTATIQN <br /> State any problems not previously noted: <br /> S . EMLATIQU DENSTTX <br /> Appx. No. People per epi. mi. <br />