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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes_ No_ <br /> Does existing septic system comply with Ord . #549 : Yes_ Noy,, <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.k_ Is well proper: <br /> Yee_ No_ State deficiency :— <br /> / (JeL -C;. 121rLiu e& Ly. a'/ <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 /> /t"A) <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 V Z^.TO F-2 NTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACTT,TTE3 <br /> No . & location existing : ^�✓h ` Additional <br /> facilities needed _ <br /> 6 . PREVIOUS , .RA=ION HISTOEtY <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted: <br /> 9 . POPU CATION DELJ,,TTY �jq <br /> APpx . No . People per sq . mi . /� <br />