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r <br /> I� <br /> 1. SEWAGE I� <br /> Distance to Public Sewers Connection necessary: Yes No <br /> Does existing septic system comply with Ord. #549: Yes No <br /> �I <br /> i <br /> Describe septic installation to be installed: IM <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes No Is well proper: Yes No ' <br /> State deficiency: <br /> I! <br /> Does existing or proposed use make this well public water: Yes No Sample of well <br /> water taken: Yes No Date taken Results <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE <br /> E Licensed scavenger pick-up: Yes No Service Area No. I� <br /> Other proposed disposal method! <br /> Potential problems: <br /> 4. FLY, MOSQUITO, OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> i� <br /> } I <br /> C '�5. TOH ET/BATH FACILITIES <br /> No. & location existing: <br /> g <br /> Additional facilities needed <br /> b. PREVIOUS OPERATION HISTORY <br /> I� <br /> I� <br /> 7, GENERAL SANITATION i <br /> State any problems not previously noted: <br /> :k <br /> I <br /> S. POPULATION DENSITY <br /> Appx, number of people per square mile I4 <br /> t <br /> I <br />