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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes_ No_ <br /> Does existing septic system comply with Ord . 0549 : 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_ 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 . ELLI, MOSQUITO OR V ECTOR pL'prNTj©L <br /> State possible vector potentiftl & necessary control: <br /> 5 . TOILET/BATH FACTLITES <br /> No . & location existing : _ Additional <br /> facilities needed <br /> 6 . PRFVTOUS OPERATION HISTORY <br /> 7 . GENERAL SAiITTATION <br /> State any problems not previously noted: — <br /> S . <br /> oted: _8 . POPULATION DENSITY <br /> Appx. No . People per sq. mi . <br /> ��. -(1�, p-te �-1,Z, RC1, , i �0 ,' G-.:[ <br />