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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 t1)is 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 . FLY. MOSQUITO OR VECTOR POLE.NTIAL <br /> State possible vector potential & necessary control: <br /> 5 . TQILET/BATH FACTt,T'iT�a <br /> No . & location exi-sting : Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HTS CORY <br /> 7 . GFNFRAL -,SALUTATION <br /> State any problems no-t previously noted :_ <br /> 8 . PGPULATIL)I Mis TY <br /> Appx . No . People per sq . mi . __ <br />