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1 . SEWAGE <br /> Distance to Public Sewers d/l" � 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 Na State deficiency : <br /> Does existing or pornosed use roake this well public water: Yes. <br /> Na Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE 4,�c <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method : <br /> Potential problem: <br /> 4 . FLY , MOSQUITO OR Y Z'ry ) 'Ci'FZNTIAL <br /> State possible vector potential & necessary control:- <br /> 5 . TQILET/BATH FACILITES <br /> No . & location existing ___ Additional <br /> facilities needed <br /> 6 . PRE�V�IQUSOPERATION =R1 <br /> 7 . GENERAL SATTI'IA'I'3OI <br /> State any problems not previously noted- <br /> 8 . <br /> oted:8 . P t P LATIQN DENSITY <br /> Appx. No . People per sq . mi ,���i�d��/�,�.��-�t�`✓/�' /.�� <br />