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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 installation to *be installed: <br /> Z . II1TER 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 /> 8 . GARBAGE & RSFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem.---- <br /> 4 . FLY. MQSQUITQ OR VC^Tc►R PO'rENTTAL <br /> State possible vector- potential & necessary control: <br /> 5 . TnILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERA TION HISTORY <br /> 7 . GENERAL SANIIATTON <br /> State any problems not previously noted : <br /> 8 . POPULATION D ,N ;TTY <br /> Appx. No. People per sq. mi . <br />