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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_ No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> 2 . WATER SUPPL`I <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 /> Na Sample of well water tarsen: 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. EL1� MOSQUITO OR -YE-CTOR ECLLHT?ATa <br /> State- possible vector potential & necessary control : <br /> 5 . TOILET/BATH FAC TES <br /> No . & location existing: _ Additional <br /> facilities needed <br /> 6 . PREVTOTTS OPERATION Di <br /> 7 . GENERAL SAIITTA1'ION <br /> State any problems not previously noted : - <br /> 8 . <br /> oted : _3 , F'O ' ILATION DENSTTY <br /> Appx. No . People per sq . mi . <br />