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i . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . 4549 : Yes✓ No_ <br /> Unknown If no , explain: <br /> Describe septic installation to be installed: c-, LW <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes _ No✓ Is well proper: <br /> Yee_ 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. $LY_� MOSQUITO OR V E^TO PCrjBMT_AL <br /> State possible vector potential & necessary control : <br /> No <br /> 5 . TOILET/BATH FACTTJTES <br /> No . & location existing : _ Additional <br /> facilities needed <br /> 6 . PREVTOCIS OPERATInN Hj$r�RY -! <br /> r <br /> 7 . , F.N .RA . SAiITTATION <br /> State any problems riot previously noted :_ <br /> 9 . POPU .ATTON DE'I,ITy 1 pp <br /> Appx. No . People per sq. mi . �Zeiid Jlc.,'( <br />