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• , a� <br /> 1 . SEWAGE [ <br /> � � <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 /> Isw ter supplied by private well : Yes No_ Is well proper: <br /> Yes No_ State deficiency : <br /> Does exist ng 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 disposal method: <br /> Potential problem: <br /> 4. ELI. MOSQUITO OR VECTOR PO'CENTTA <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing : — Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted : - <br /> 8 . <br /> oted : _S . EOPULATTON DENSITY <br /> Appx. No . People per eq. mi. <br />