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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 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 . FLY, MOSQ.UITQ OR_Y ''--"aa--Z9T1N`rIAL <br /> State possible vector potential & necessary control ! <br /> 5 . TQILET/BATH FACTLT'I'ES <br /> No. & location existi,ig : __ Additional <br /> facilities needed-- <br /> 6 . <br /> eeded _6 . PREVIOUS OPERATION H_LiMaX <br /> 7 . GENERAL SANITA`T'I0- 1U <br /> State any problems not previously noted : <br /> 8 . POPULATION DENSIT-1 <br /> Appx . No . People per (,q. mi ., _ _ _ <br />