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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic s em comply with Ord . #549 : Yes No_ <br /> Unknown If no, a a.in: <br /> Describe sept a installation to be installed: <br /> 2 . MATER SUPPLY <br /> Is water supplied by private we' 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 Late aken _ <br /> Results Additional information <br /> Ap <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem :-- <br /> 4. <br /> 4. ZL.J. MOSQU I TQ OR V E^.TO PC)fENTI.©1.0 <br /> State possible vector potentiftl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SAPIIT '1,A ,ION <br /> State any problems nob previously noted: _ <br /> 8 . POPULATION DENSTIX <br /> Appx . No . People per eq. mi. <br />