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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 /> Z . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> YesNo State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water taken: Yes Na 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 . FLYS MOSQUITO QR VQjj_PS'f ENTIAL <br /> State possible vector potentiftl & necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : _ Additional <br /> facilities needed _ <br /> 6 . PREV_TO(TE OPERATION HIS'rORY <br /> 7 . GENERAL SAIJIT '1-A ION <br /> State any problems not previously noted : <br /> 8 . POPULATTON DENSITY <br /> Appx. No . People per oc mi . <br />