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1 . SEWAGE <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 /> 6> <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes Is well proper: <br /> Yeses No State deficiency : <br /> Does existing or porposed use make this well public water : Yes— <br /> No— <br /> esNo - 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 . FLYS MOSQUITO OR. YE M)R—M) IAL <br /> State possible vector potential & necessary control : <br /> 5 . ILET/BATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed—_- <br /> 6 . <br /> eeded _ —6 . PREVIOUS OPERATION H_ ORY <br /> 7 . GENERAL SANIIA'l'I A <br /> State any Problems not previously noted : -- <br /> 8 . <br /> oted : _8 . POPULATION D .NSIT-1 <br /> Apex. No . People per eq. mi . _ <br />