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1 . SEWAGE <br /> Distance to Public Sewers N 4 Connection necessary: Yes No <br /> Does existing septic system comply with Ord . 0549 : Yes= No_ <br /> Unknown If no , explain : <br /> Describe septic installation to be installed: <br /> Z . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes_ No_ State deficiency ! <br /> Doee, existing or porposed use make this well public water : Yes <br /> No /J 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 V CTO ZC)rE ITIAL <br /> State possible vector potential ?z necessary control : <br /> V"� <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PRF.VIOUs nPL+.RATION HISTogX <br /> 7 . GENERAL SANIT �1A 'ION <br /> State any problems not previously noted :_ <br /> N tii11 <br /> 8 . POPULATION DENSITY N <br /> Appx. No . People per sq . mi . <br />