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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes_ Nox <br /> Does existing septic system comply with Ord . 0549 : Yes= No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> 2 . WATER EUPPI Y <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 X Sample of well water tarsen: Yes_ No_ Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSF <br /> Licensed scavenger pick-up: Yes_ No_ Service Area No. <br /> Other proposed disposal method: <br /> Potential problem : <br /> 4 . =. MOSQUITO OR V ZQ E.Q:Ma-TAA <br /> State possible vector potential & necessary control : <br /> G- <br /> 5 . TOTLFT/BATH FACILITES <br /> No . & location existing : — Additional <br /> facilities needed <br /> 6 . PREVIOUS OPFRATInid H ETM <br /> 7 . GENERAL SANITATION <br /> State any problems nob previously noted : — <br /> o <br /> lC_- <br /> 3 . EOP11LATTON DENSITY <br /> Appx . No . People per sq. mi . <br />