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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes No;'L <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 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 . FLYS MOSQUITCj OB_y Z � '2TENTIAL <br /> State possible vector potentin.l & necessary control : <br /> 5 . TOILET/BATH FACILITY <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTDfM <br /> 7 . GENERAL SANITA17 N. <br /> State any problems not previously noted: -- <br /> 8 . <br /> oted: _8 . F SPUL ` TQ SITY <br /> Appx. No . People per so . mi ._ <br />