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1 . SEWAGE <br /> Distance to Public Sewers _. - onnection necessary : Yes, N0.2L <br /> Does existing septic system comply with Ord . 4549 : Yes-,!(-- No_ <br /> Unknown If no, explain: / <br /> De cribe s tic installation to be ins al] ed ✓����C- <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well: Yes No Is well proper: <br /> Yes`' No <br /> State deficiency: <br /> Does a isting or porposed use make this well public water: Yes <br /> NoSample of well water taken: Yes_ Nom 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 . ZLLY�L1OSQUITO OR VECTOR PS)TLIT_TAT..L � <br /> State possible vector potentir,l Az necessary control : �oa� <br /> 5 . Z,ILET/BATH FACILITES <br /> No . & location existing: _ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION MST=, <br /> 7 . GENERAL SA �ITATION <br /> State any problems not previously noted : �o -� <br /> 9 . POPULATION DENSITY <br /> Appx . No . People per sg . rai 9�✓l'���-�� — �'�/i�F � L <br />