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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes_ No_ <br /> Does existing septic system comply with Ord . 4549 : 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 /> Ne 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 . MOSQUITO OR VJ:'Tn E-201MIATIL <br /> State possible vector potential F,c necessary control : <br /> 5 . TOILET/BATH FACI1,TTFS <br /> No . & location existing : _ Additional <br /> facilities needed---- <br /> 6 . <br /> eeded —_6 . PREVIOUS QPER.ATT IN <br /> 7 . GENERAL SAt1TTAJON <br /> State any problems not previously noted : - <br /> 8 . <br /> oted : _S . Drt�,,ITv <br /> APPx . No . People per eq. mi . <br />