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w <br /> 1 . SEWAGE <br /> Distance to Public Sewers '` Ovconnection necessary : Yes No_ <br /> Does existing septic system comply with Ord. #549 : Yes No_ <br /> Unknown If no, explain : S y� <br /> Describe septic installation to be installed: <br /> 2 . WATE SUPPLY <br /> Is wate Supplied by private well : ;4Ds No Is well proper: <br /> Yes No St <br /> Does e sting 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 /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLY,- MO QUITO OR VECTOR F-CUKRZIAL <br /> State possible vector potentiTt.l & necessary control - <br /> 5 . TQILET/BATH FAG= <br /> No . & location existing: — �__ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION H=am <br /> 7 . GENERAL SANI'rA'1,LQA <br /> State any problems not previously noted : <br /> 3 . ) :TLATIQN DE1=1 <br /> Appx . No . People per sq. mi . <br /> tr. <br />