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1 . SEWAGEi <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 . MATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes No State deficiency .- <br /> Does <br /> eficiency :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, MOSQUITO OR YECTOR PO'PE}�TIAL <br /> State possible vector potential & necessary control : <br /> 5 . TQILET/BATH FACILITY <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANIT,(, T-T-L-N <br /> State any problems not previously noted: - <br /> 8 . POPULATIt N T)F SIT`, <br /> Appx . No . People per sq . mi ._ <br />