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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 instillation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied b-y private well : lies 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 OE V Ca-EC'rNT Ari <br /> State poesible vector potential. & necessary control : <br /> 5 . TQILET/BATH FACILI`Ma <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANITA`i IM <br /> State any problems not previously noted. : _ <br /> 8 . POPULATIOl4 £ENSI-TI <br /> APpx . No . People per i•ci. mi. -- - - - <br />