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1 . SEWAG,E <br /> Distance to Public Sewers Connection necessary: Yes_ No_ <br /> Does existing septic system comply with Ord . 41549 : Yes_ No_ <br /> Unknown If no , explain: <br /> Describe septic installation to be installed: <br /> 2 . RATER 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: Ye-s_ 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 disposal method : <br /> Potential problem : <br /> 4 . FL_L MOSQUITO OR V QTO) aC)�rLU TATj <br /> State possible vector potentir)1 & necessary control : <br /> 5 . TOTLET/BATH FACILTTES <br /> No . & location existing : _ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HS.,`= <br /> 7 . GENERAL SAtUTAT10N <br /> State any problems not previously noted :- <br /> 8 . <br /> oted :S . PnPi?LAT TQj4 DENSITY <br /> Appx. No . People per rq. mi . <br />