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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes No_ <br /> Does existing septic system comply with Ord . 0549 : Yes No-- <br /> Unknown---- <br /> o_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: V <br /> 4 . FLYL MOS QUITO OR ATOR PS�TIdNTILL <br /> State possible vector potential & necessary control : <br /> 5 . LET/BATH FACT LITS <br /> No. & location existing : __. Additional <br /> facilities needed <br /> 6 . BREVIOUS OPERATION H1TDRY <br /> 7 . GENERAL SANITAXTFION <br /> State any problems not previously noted: __ _ <br /> 8 . POPULATIQN DE EITY <br /> Appx. No. People per sq.. mi . - <br /> _ <br />