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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 SUPPLY <br /> Is water supplied by private well : Yes NZI� Is well proper: <br /> Yes No State deficiency ' — <br /> Does existing or porposed use make this well public water : Yes <br /> No�_ Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> icensed scavenger pick-up: Yes No Service Area No . <br /> 0 er proposed disposal method: <br /> Pot tial problem: <br /> 4 . FLY TITTOAR Y EC)PENTIAL <br /> State pos ,b le vector poteritinl & necessary control ! <br /> 5 . TOILET/BATH FAGILIT <br /> No . & location existAdditional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION <br /> 7 . GEN RAL SANI'I <br /> State any probl s not previously noted. _ <br /> S . POP ITY <br /> Akpk. No. People per sy.. mi ._ <br />