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1 . SEWAGE <br /> Distance to Public Sewers /y Connection necessary : Yes NqZ <br /> Does existing septic system comply with Ord . #549 : Yes, No_ <br /> Unknown If no, explain: <br /> escribe sept c 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 xisting or porposed use make this well public water: Yes <br /> NoSample of well water taken: Yes NoDate 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 . FLY MOSQUITO OR Y 1" M—EC)UNTIAL <br /> State possible vector potential & necessary control : �l'c�C` <br /> 5 . TOILET/BATH F_ACIIIIFM <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANITfTIOJ <br /> State any problems not previously noted: _��� <br /> 8 . POPULATIQN DENSITY <br /> Appx. No . People per sq. rrii . ���1'/, if �fi•®F9',�-'frc' <br />