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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . #549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 2 . WATER SIIPPLY <br /> Is water supplied b°:1T private well : Yes No Is well proper: <br /> Yes No State deficiency : <br /> Dees existing or porposed use make this well public crater: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 , GARBAGE & RRF_CISE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem:­ <br /> 4 . FLY, MOSQUITO OR VrQ-1 QQR PQ'Ej,;HT.AL <br /> State possible vector potentircl ?A necessary control: <br /> 5 . TOILET/BATF FA(:I LITFS <br /> No . & location existing: Additional <br /> facilities needed <br /> 6 . PRFVTOUS Q29RATT0N HI^T0 <br /> 7 . GENERAL SANTTATTQN <br /> State any problems not previously noted: <br /> 9 . P01!Q .ATION DF.,'N4SaTTv <br /> Appx. No. People per sq. m i . <br />