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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 . NATER 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 Additi,mal information or comments <br /> 3 , GARBAGE & REFUSE <br /> Licensed scavenger prick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MQSQUITO QR Vr�TQR PQ'rCNTTA <br /> State possible vector potentiftl & necessary control: <br /> 5 . TOILET/BATH FACI ITE5 <br /> No . & location existing: Additional <br /> facilities needed <br /> 6 . PRRVIOna C) 4RAT nN HISTORY <br /> 7 . GENERAI. SANITATION <br /> State any problems not previously noted: <br /> S . POPEIL.ATTON DEYSTTv <br /> Appx . No. People per eq. mi. <br />