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1 . SAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . 3549 : 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 NO-0,_. <br /> oIs well proper: <br /> Yes No State �B'` <br /> Do isting or porposed use ake this well public water: Yes <br /> Noes x� Sample of well water taken: Yes Nom Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yeses No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . ELY, MOSQUITO OR V ,,^. O PO' ,NTIAL <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH FACItJTES 41 - <br /> No . & location existing Additional <br /> facilities needed <br /> 6 . PRFLVTons op gATION HISTngX <br /> 7 . GENERAL. SANITATION <br /> State any problems not previously noted , <br /> 3 . POPULATION DENSITY <br /> Appx. No . People per sq. mi . <br />