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1 . SAG <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 SUPPLY <br /> Is wa er 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 /> Resul s Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes4 No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLYS MOSQUITO OR y Q I ECi'FENTIAL "'// <br /> State possible vector potential & necessary control : ��y� <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : - Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted : <br /> 8 . POPULATION DENSITY 1 / <br /> Appx . No . People per sq. <br />