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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�xisting 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 . FLYS MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control : *t'" <br /> 5 . TQILET/BATH FACILI7T <br /> No . & location existing : _ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> e <br /> 7 . GENERAL SANIT/, TTO� <br /> State any problems not previously noted: <br /> 3 . POPULATION DENSITY �! <br /> Appx. No. People per sq. mi . <br />