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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 . {CATER 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 pick-up: Yes— No_ Service Area No. <br /> Other proposed disposal method: <br /> Potential problem : <br /> 4 . FLi, MOSQUITO OR -YECTOR-VECTORPOrE19TIAT, <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATE FACILTTES <br /> No . & location existing : Additional <br /> facilities needed__ <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANITAT -�In <br /> State any problems not previously noted : <br /> 3 . POPULATION DENSITY <br /> Appx . No. People per sq. mi . <br />