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1 SEWAGE <br /> Distance to Public Sewers 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 /> 2 . EATER 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 we'll public water : Yes <br /> No ✓ Sample of well water taken : Yes_ No� Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & RF.F TS . <br /> Licensed scavenger pick-up: Yes— No_ Service Area No . <br /> Other proposed disposal method : <br /> Potential problem: <br /> 4 . ELY MOSQUITO OR -YECTOR POPENTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing : __ Additional <br /> facilities needed —_ <br /> 6 . PREVIOUS OPERATION HIST <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted: _ <br /> 8 . POPULATION DENSITY <br /> Appx. No . People per sq. mi . <br />