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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 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. FJLY. MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control : <br /> 5. TOILET/BATH FACILITES <br /> No. & location existing : __ Additional <br /> facilities needed <br /> 6 . PREVIOUS RATION HIST_._BY. <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted: -- <br /> 8 . <br /> oted: TS . POPULATION DENSITY <br /> Appx. No. People per sq. mi . <br />