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a <br /> 1• SEWAGE <br /> J ti <br /> Distance to Public Sewers Connection necessary: Yes/—"' <br /> es/ No— <br /> Does existing septic system comply with Ord . 0549 : Yes No,_ <br /> Unknown If no, explain : <br /> Describe septic installation to installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is Drell proper: <br /> Yes No State deficiency: <br /> /l , <br /> lM <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 & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposa method <br /> Potential problem : ��c ap"=A Tom X- -Pati ,fa � =��;�►e <br /> 4 . gj,gL MOSQUITQ OR V E^.T0) PC'I'I;NTIAL <br /> State possible vector potentiFtl & necessary control : <br /> 5 . TOILET/BATH I'ACILITES <br /> No . & location existing : _ Additional <br /> facilities needed- <br /> 6 . <br /> eeded6 . PREVI t1S OPERATION HISTO <br /> 7 . GENERAL SANI AZ-ON <br /> State any problem; not previously noted : _ <br /> C �� 1 ohi, - y /o� <br /> 8 . P_OPULATION DENt,,ITY <br /> Appx. No . People per oq . mi . <br />