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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes No_ <br /> Does existing septic system comply with Ord . 3$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 mater taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE. & RFFOSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed dispoe.il method: <br /> Potential problem: <br /> -- <br /> 4 . FLY, MQSAUITQ QR V ,CT�2jL_POTLNTIAL <br /> State possible vector- potential +8.c necessary control: <br /> 5 . TnILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed 6. PREV IOnS OP ,.RAT O.N HZ�`',TQRY <br /> 7 . GENERAL SAITTTATTON <br /> State any problems not previously noted: <br /> 3 . POPULA Tn7 DENSTIX <br /> Apex. No . People per ac . mi. <br />