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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, — State deficiency : <br /> Does existing or porposed use make- this well public water: Yes <br /> No Sample of well water tarsen: 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 . FILY� MOSQUITO OR y Z•,TO PCMET1AL <br /> State possible vector potential & necessary control : <br /> 5 . TQILET/BATH FAQILITFS <br /> No. & location existing : Additional <br /> facilities needed <br /> 6 . PREpVIOUS QPER.ATION HI, D- <br /> vJ • � s- �'hm' <br /> 7 . GENERAL SA HTATION <br /> State any problems not previously noted :_ <br /> 3 . PO ILATION DENSITY <br /> Appx . No . People per sq . mi . <br /> dog5AV e ce <br />