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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 /> ..� f <br /> Describe septic installation to be installed : <br /> T r 7� <br /> 2 . WATER SUPPLY t) ez'l 3 <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes Na State deficiency : —_ <br /> Does e isting or porposed use make this well. public water: Yes <br /> No Sample of well water taken: Yes Na Date taken <br /> Results Additional information or <br /> 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 . FLY. MOSQUITO OR YECTOR 20 FEMAL <br /> State possibly: vector potential & necessary control : <br /> 5 . ILETfBATH FACILIZEa <br /> No . & location existing - —_. Additional <br /> facilities needed _ <br /> 6 . PREVIOU2 OPERATION HISTORY <br /> f � <br /> r <br /> cl <br /> 7 . GENERAL SANITATIQU <br /> State any problems not previously noted : <br /> S . POPULATIQUE -Y- <br /> Appx . No . People per sq . mi . - — <br />