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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 /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is dell proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make- this well public water: Yes <br /> No Sample of well water tarsen: 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 . ZLY_,_ MOSQUITO OR VE^.T0j�_ )'frNjjATa <br /> State possible vector potentiFtl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PREVIOTTS OPERATION HI STORY <br /> 7 . GENERAL, SANIL&TION <br /> State any problems not previouLly noted : — <br /> S . POP 1 ,ATInN )Fi `'T v <br /> Appx. No. People per rn . mi . _ <br />