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1 . MAGE <br /> Distance to Public Sewers Connection necessary : Yes— No_ <br /> Does existing septic system comply with Ord . #549 : Yes_ No_ <br /> Unknown If no, explain : <br /> Describe septic installation to be installed: <br /> 2 . WAT .R 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 . GARRAnE & R6FUS6 <br /> Licensed scavenger pick-up: Yes— No_ Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: - <br /> 4 . FLY . MOSQUITO OR VF_C_TOR_ POTENTIAL <br /> State possible vector potentiatl & necessary control: <br /> 5 . TOILET/BATH FACIL.ZTF.a <br /> No . & location existing : Additional <br /> facilities needed <br /> 6. PRRVIORS OPRRATIOH HISTORY ( r <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted: <br /> S . POPULATION DR�,4SITY <br /> Appx . No . People per Bq. mi . <br />