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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 : y s STs well proper: <br /> Yes Notate deficiency : <br /> Does e�sting or porposed use make this well publicwater: Yes <br /> No ✓ Sample of well water taken: Yes— No Date t ken <br /> Results Additional information or comments � �� <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . MY-1SMOSQUITO OR y ' "" 1 E2EENTIAL <br /> State possible vector potential & necessary c=ontrol : <br /> 5 . TOILET/BATH FACI=.'Ea <br /> No . & location exi=sting : _ Additional <br /> facilities needed _ �- <br /> 6 . PREVIOUS OPERATION H=fjEff <br /> 7 . GENERAL SANITA'1'1_tlU <br /> State any prolDlems not previously noted: <br /> 8 . POPULATIQL4 DE al _ <br /> Appx . No . People per eq. mi . _ _ <br />