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1 . 5EWAGFi <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 /> Z . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes No State deficiency : <br /> Doesy �acisting 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, & REFI[SF. � <br /> Licensed scavenger pick-up: Yes � No Service Area No . <br /> Other proposed disposal m io . <br /> Potential problem: <br /> 4 . =L MOSQUjjQ QREQTOR PQ fj2jT?&L <br /> State possible vector potentit,i necessary control . <br /> 5 . TOILET/BATH FACILITES a <br /> No . & location existing: Additional <br /> facilities needed _ <br /> 6 . PREVTOnS OPERATION H ; M, i ,A <br /> F 1 _' ria <br /> 7 . QENERAL SANI'r 'lti 'Ic_N <br /> State any problem; not previously rioted: <br /> 1 <br /> 3 . MTILATION DENSIT! <br /> Appx. No . People per sq. mi . <br />