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1 . SrkWAGE <br /> Distance to Public Sewers Connection necessary: Yes_ No_ <br /> Does existing septic system comply with Ord , 11549 : Yes_ No_ <br /> Unknown If no , explain: <br /> Describe septic installation to be installed: <br /> 2 . WATER SUpPr,Y <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 . �AB�FaS: Fc._FSSF[TSS_E_ <br /> Licensed scavenger pick-up: Yes— No_ Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: _ <br /> 4. FLY, MOSQUITO OR Vb_y^.TOR POTUT-IAI, <br /> State possible vector potential & necessary control: <br /> 5 . TOT ,FT/BATH FACILITFa <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PRFVTOfTS C) T;TORY <br /> 7 . GENERAL SANITATTON <br /> State any problems not previously noted: <br /> S . P(1 CP ILAZ _ ti I)r1 <br /> Appx. No . People per sq. mi. <br />