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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 /> 2 . WATER 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 . FLY. MOSQUITO OR YECTOR PrJaNTIAL <br /> State possible vector potential & necessary control - <br /> 5 . TQILET/BATH F&C-LILITES <br /> No . & location existing ! _ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HJa.TL}RY <br /> 7 . GENERAL SANITATI01. <br /> State any problems not previouBly noted: <br /> 3 . POPULATIQN DEtj=Y <br /> Appx . No . People per sq . mi . - <br /> _� <br />