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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yesx_ No_ <br /> Does existing septic system comply with Ord . #549 : Yes No_ <br /> Unknown If no, explain: <br /> Descch�gibe septic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes No State deficiency : <br /> Does existing 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 . =, MOSQUITO OR V {C ECUENTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TQILET/BATH FACILITY <br /> No . &. location existing : _ Additional <br /> facilities needed <br /> 6 . PREYQUS OPERATION HISTORY <br /> 7 . GENERAL SA14ITATION <br /> State any problems not previously <br /> S . POPULATION DE14SITY <br /> Appx . No . People per sq. mi . �.__ <br />