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1 . SEWAGE <br /> Distance -to Public Sewers Connection necessary : Yes Na_ <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 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 . FLY-,,- MOSQUITO OR Y 1 n 1 ECi'EENTIAL <br /> State possible vector potential & necessary control : <br /> 5 . T�)I E� T/BATH FACILIM <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION =DRY <br /> 7 . GENERAL SANI'T'ATION <br /> State any problems not previously noted: _ <br /> 3 . POPULATION DEt=11 <br /> Appx. No . People per sq. mi ._ <br />