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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . tt549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY 1 / <br /> Is water supplied by private well : Yesy 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 . ELL,- MOSQUITO OR V ^TO PS�'PrnTz <br /> State possible vector putentiftl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: Additional <br /> facilities needed _ <br /> 6 . PR .VIOfIS OP .RATION HI STORY <br /> 7 . GENERAL SAPIIT '1.A 'ION <br /> State any problems not Previously noted : - <br /> 8 . <br /> oted : _8 . POPULATION DFL`Li?TY <br /> Apnx. No . People per sq . mi . <br />