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1 . SrWA X <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 token: yes_ No_ Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yea ✓No_ Service Area No . <br /> Other proposed disposal method: <br /> Potential problem:_ <br /> 4 . F .Y. MOSQUITO OR VECTOR POTENTIA . <br /> State possible vector potential 8i necessary control: <br /> 5 . ZpILETiBATH FACILITES <br /> No . & location existing: Additional <br /> facilities needed pig <br /> 6 . pREVIOUS OPgRATION HISTORY <br /> 7 . GENERAL SANITATION <br /> State any problems not Previously noted: <br /> S . POPULATION D&YSrTY <br /> Appx , No . People per aq . mi . <br />