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1. SEWAGE <br /> Distance to Public Sewers NII�A Connection nec ;nary: Yes No <br /> Does existingheptic system comply with Ord. #549: Yes ✓✓ No <br /> c� .4 # 71-1-2-( <br /> Describe septic installation to be installed: <br /> 2. WATER SUPPLY / <br /> Is water supplied by private welly /Yes No Is well proper: Yes r <br /> State deficiency: 1 <br /> Does existing or proposed use ma a this well public water: Yes_N ASample of well <br /> water taken: Yes No _Date taken A)1A_ Results A.) A <br /> Additional information or comments: Q ca,, a r JR L�• SNS,4�,,» <br /> 3. GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes _ No _ Service Area No. <br /> Other proposed disposal method: <br /> Potential problems: <br /> 4. FLY, MOSQUITO. OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5. TOILETIBATH FACILITIES <br /> No. & location existing: <br /> Additional facilities needed <br /> 6. PREVIOUS OPERATION HISTORY <br /> 7. GENERAL SANITATION <br /> State any problems not previously noted: <br /> 8. POPULATION DENSITY <br /> Appx. number of people per square mile <br />