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1 SAGE <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 x 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 . <br /> roblem: _4 . FL -L MOSQUITO OR VEf.-TOR POTENTIAL <br /> State possible vector potentihl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted: - <br /> 8 . <br /> oted: _8 . POPULATI-A DENSITY <br /> Appx . No . People per sq. mi . <br />