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1 . SSWGE <br /> Distance to Public Sewers Connection necessary: Yes_ No_ <br /> Does existing septic system comply with Ord. 41549 : Yes_ No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> l_or-/u.- a 74-i <br /> 2 . VATFR SUPPLY <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 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. ELY. MOSQUITO OR VECTOR PO''C :.NTTAL <br /> State possible vector potential & necessary control: <br /> aSGA' - '4s-50 �y / <br /> 5 . TOT L •T/BATH FACILITES �4✓K�S <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . PRFVIOUS OPLRATION HTSTORY <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted: <br /> 3 . POPU ,A'I OtI 7 DENSITY <br /> Appx. No . People per sq. mi . <br />