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A <br /> 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 <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. FLY. MOSQUITO OR V .CTOR PQ'C :NTTA , <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH FACILTTES <br /> No. & location existing : Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SAN TATION <br /> Sta.te any problems not previously noted: <br /> S . POPULATION D .NSTTY <br /> Appx. No. People per sq. mi . <br />