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1. SRWAGE <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 well proper: <br /> Yes_ No_ State deficiency : <br /> Does existing or porposed use make this well public water: 'les <br /> No Sample of well water taken: Yes_ No_ Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGF. & REFUSE <br /> Licensed scavenger pick-up: Yes— No_ Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FT.Y . MOSQUITO OR 70TORPO'LGNTTA , <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH FACILTTFS <br /> No. ec location existing: Additional <br /> facilities needed <br /> 6. PREVIOUS 01!RRATTON HISTORY <br /> 7 . G .N .RA , SANITATION <br /> State any problems not previously noted: <br /> $ , POPULATION DEMSTTY <br /> Appx. No. People per eq. mi . <br />