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a <br /> Ale ' . <br /> 1. SEWAGE � � <br /> Distance to Public Sewers Connection necessary: Yes No ' <br /> Does existing septic system comply with Ord. 4549: Yes No <br /> Describe septic installation to be installed: <br /> WATER SUP �� <br /> SUPPLY <br /> 2. . _ Y <br /> Is water supplied by private well: Yes No [--'Is well proper: Yes No <br /> State deficiency: <br /> Does existing or proposed use make this well public water: Yes No`'_~Sample of well <br /> water taken: Yes No Date to n Results <br /> Additional information or comments: i <br /> 3. GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problems: <br /> 4. FLY MOS UITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5. TOILETBATH FACILITIES <br /> No. & location existing: } <br /> Additional facilities needed <br /> 6. PREVIOUS OPERATION FIISTORY <br /> 7. GENERAL SANITATION <br /> State any problems not previously noted: <br /> S. POPULATION DENSITY <br /> Appx. number of people per square mile <br /> i <br />