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1 . SSE <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. 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 & RRFUSE <br /> Licensed scavenaer pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: _ <br /> 4. FLY . MOSQUTTO OR. TQTQR P0'j' :NTIAL <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH FACTL ITES <br /> No. & location existina: Additional <br /> facilities needed - <br /> 6 . PREVTOna OPERATION HISTORY <br /> 7 . GENERAL SANITIA TON <br /> State any problems not previously noted: <br /> 8 . popU .ATTON pXH3TTY <br /> Apnx . No . People per eq. mi. <br />