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r <br /> 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 SUPPI,'i <br /> Is water supplied by private we11 : Yes No `""" Is well proper: <br /> Yes No State deficiency : <br /> Does isting or porposed use make this well public water : Yes <br /> No3 ample of well water -taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GA$BAGE & REFUSE <br /> Licen's`ed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLYS MOSQUITO OR V ;T � �rrNTIAL, <br /> State- possible vector potenti-ii & necessary control : <br /> 5 . TOTLET/BATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HIST <br /> 7 . GENERAL SANITATION. <br /> State any problems not previously noted : _ <br /> 8 . POPULATIQN DENSITv. <br /> Appx. No . People per sc; . mi . <br />