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1 . SEWAGE - <br /> Distance to Public Se;wera___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 water supplied b,,� private well : Yes No Is well proper: <br /> Yes No State deficiency : <br /> Does e ting or porposed use make thies well p blic water: Yes <br /> No Sample of well water taken: Yes � Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes o Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . ELY,_ MOSQUITO OR IECTQR FO'TJ,NTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TQILET/BATH FAC IL 'II ,ES <br /> No . & location existing ., __ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANIM:l.'I M. <br /> State any problems not <br /> 8 . POPULATIQ14 DEySIT-1 <br /> Appx . No . People per Tal . _-_—_-- <br />