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1 . SRWAGE <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 . WATER 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 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 d'_ _posal method: <br /> Potential proble,;. Iva <br /> 4 . F[,y , MOSQUITO OR VECTOR ECIrL T.ItLL <br /> State possible vector potential & necessary control : <br /> �� Q�i�'�i� /1ns'GP-•v <br /> 5 . TOTLET/BATH FAt'I TTES <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> =X, ov �� is d,✓idro- ro �. <br /> 7 . GENERAL SA23TATTON <br /> State any problems riot previously notad:OK- <br /> 9 . P()PUL,ATION DL-,Y Tl <br /> Appx . No . People per sq . mi . <br />