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i <br /> f <br /> 1. SEWAGE <br /> Distance to Public Sewers Connection necessary. Yes No <br /> Does existing septic system comply with Ord. #549: Yes No <br /> Describe septic installation to be installed: <br /> i <br /> 2. WATER SUPPLY ".= <br /> Is water supplied by private well: Yes No Is well proper: Yes No <br /> State deficiency: <br /> i <br /> I <br /> Does existing or proposed use make this well public water: Yes No Sample of well <br /> water taken: Yes No Date taken Results <br /> Additional information or comments: <br /> GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: ! <br /> Potential problems: <br /> 4. FLY, MOSQUITO, OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> I <br /> 5. TOILETBATH FACILITIES <br /> No. & location existing: <br /> Additional facilities needed <br /> 6. PREVIOUS OPERATION HISTORY _ y <br /> 7. GENERAL SANITATION <br /> State any problems not previously noted: <br /> S. PQXjjLAjMgLUNSITY l� �� �. � <br /> Aprx. numher��areRrn —� ��a <br /> 5�esr psi <br />