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1 . SEWAGF <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord. 0549 : 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 & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR MTOj -PCTI;NTIAL <br /> State possible vector potentiftl eA necessary control : <br /> 5 . TOTLET/BATH FACTLTI'ES <br /> No . & location existing- Additional <br /> facilities needed <br /> 6 . PREVIO 12 OPERATION HISTORY <br /> 7 . GENERAL SANTTATION <br /> State any problem: not previously noted : _ <br /> 9 . POPULATION D .NSTTY <br /> Appx. No . People per Bq . mi. <br />