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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes No-4� <br /> Does existing septic system comply with Ord . #549 : Yeses No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is w er supplied by private well : Yee No Is well proper: <br /> Yes-4— No State deficiency : <br /> Does existing or porposed use make this well pub is water : Yes <br /> No Sample of well water taken : Yes No?Date taken <br /> Re7ul'ts 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 . FLY MOSQUITO OR yECTOR PO'LZMAL <br /> State possible vector potential & necessary control :_ ��� <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : --- Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANITA'rI IR <br /> State any problems; not previously noted- <br /> S . <br /> oted:S . POPULATIQN DEj=j ' <br /> Appx . No . People per sq . <br />