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1 . SAGE <br /> Distance to Public Sewers 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 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 /> Licenaed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLY,- MOSQUITO OR VB^. 2 E i'j11NTIAL <br /> State possible vector potentifil & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PREVTOMS OPERATION HISTORY • <br /> 7 . GENERAL SA14T '1,A 'ION <br /> State any problems not previously noted: _ <br /> 8 . POPULATIO14 DEN STTY <br /> Appx. No. People per BQ . mi . <br />