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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No-- <br /> Does <br /> o_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 /> Licensed scavenger prick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . ELI,- MQSQUITQ OR Y M c) ECUMUTAL <br /> State possible vector potential & necessary control : <br /> 5 . TQ .E f ATH FACILITES <br /> No . & location existing: ___. Additional <br /> facilities needed _- <br /> 6 . PREVIOUS OPERATION HI 'aT(_ RY <br /> 7 . GENERAL SANITA1=1 <br /> State any problems not previously noted: ------- <br /> 8 . <br /> _8 . POPULATION DENUTY <br /> Appx . No. People per eq . mi . _ <br />