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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes No4 <br /> Does existing septic system comply with Ord. 41549 : Yes No_ <br /> Unknown If no, explain : <br /> Describe septic inqtalation to be nstalle : <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes ,� No Is well proper: <br /> Yes-Z.- No State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No_-14- Sample of well water taken: Yes Nom Date taken <br /> Results Additional information or comments "-"'!— .,; E� <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yeses No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem : iel <br /> 4 . FLI. MOSQUITO OR VZ^.TC) EC)MNTIAL <br /> State possible vector potential & necessary control : off <br /> 5 . TOILET/BATH FACIT-ITESS <br /> No . ec location existing. /yam Additional <br /> facilities needed M _ <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SAIJIT �l_A 'ION <br /> State any problems not prevlously noted:.���E <br /> S . POPULATION DENSITY / <br /> Apex. No . People Der B . mi <br />