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1 . SEWAGE <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 . 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 . FI�Y. MOSQUITQ OR c"�' PS'fTNTJAL <br /> State possible vector potential & necessary control : <br /> 5 . TQILET/BATH FACILI ' .S <br /> No . & location existing : _ Additional <br /> facilities needed <br /> 6 . PREVTO17S OPERATION HISTORY <br /> 7 . GENERAL SAP�IT,}ATION <br /> State any problem: not previously noted : _. <br /> 8 . POPULATION DENSTly <br /> ADnx. No . People Tier sn . mi . <br />