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I . 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 /> 2 . WATER SUPPLY <br /> Is water supplied b-%7 private well : Yes No.__ Is well proper: <br /> Yes � No State deficiency : <br /> IN, <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 & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLY,- MOSQUITO OR Y 1^2M) Pyr=IAL <br /> State possible vector potential & necessary control : <br /> 5 . TQTLFT/BATH FACILITES <br /> No . & location, existing * _ Additional <br /> facilities needed ._ _ <br /> 6 . PREVIOUS OPERATION <br /> 7 . GENERAL SAtITT L`J,'TON <br /> State any problems not previously noted : _ <br /> 8 . POPULATION DENSIT-Y <br /> AUnx . No . People per eq. mi . <br />