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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. MATER SUPPLY <br /> Is water suppliedby 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 . <br /> roblem:4 . FLY. MOSQUITO OR VMOTO) PSP ,NTIAL <br /> State possible vector potentirtl & necessary control: <br /> 5 . TOILET/BATH FACTLTTES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVIOUS OPERATION HT 1M <br /> 7 . GENERAL SMITTATTON <br /> State any problems not previously noted : <br /> 3 . POPULATION DENSTT`? <br /> Appx . No. People per s1 . mi . <br />