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1 . SAGS <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 dater taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger p:-,ck-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem:- <br /> 4. <br /> roblem:4. ELY. MOSQUTT2 0!3 v ,^.^ PQ'[CNTTA , <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH FACTL,ITES <br /> No . & location existir:g: Additional <br /> facilities needed-- <br /> 6 . <br /> eededa6 . PREVTnnS OP tRATTOM HTFTM <br /> 7 . C .N .RAL SANI:CATT_ON <br /> State any problems not previously noted : . <br /> S . PPOPULATION DENSTTY <br /> Appx. No. People per ca . mi. <br />