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4 f SEkIAGE <br /> Distance to Public Sewers Connection necessary: Yes No— <br /> Does existing septic system comply with Ord. #545 : Yea - No_ <br /> Unknown— If no, explain: <br /> Describe septic installation to 'be installed: <br /> Z. WATER 192ULY <br /> Is Water supplied. by private well : Yes No Is well proper: � <br /> Yes No State clef ieieney <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well Water taken: Yee 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. ELY, MOSOUITO 08 VEQTnR EOTENTIAL j <br /> State possible vector potential necessary control: <br /> i <br /> I <br /> 4 <br /> I <br /> I <br /> 5 . TOTLET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . EREVTOUS f:PEH,&TjgH HTSTORXi <br /> 7 . GENERAL SMIITATION k <br /> State any problems not previously noted: <br /> 3 . MPULATIdN DENSITY <br /> Appx. No. People per .sq. mi . <br />