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f <br /> 1 . S "' � <br /> Distance to Public Sewers Connection necessary: Yes No4 <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 SUPPLY <br /> Is water supplied by private well : Yes 4 No_ Is well proper: <br /> Yeses No_ State deficiency : <br /> Doe existing or porposed use make this well p blic water! Yes <br /> NoSample of well water taken: Yes_ No T/ Date taken <br /> Results Additional information or eomm6;nts <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes-14 No_ Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . ELY MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: e6 <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: 111�� Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANITATION I/ <br /> State any problems not previously noted: <br /> 8 . POPULATION DENSITY 9ri�� � <br /> y���FAppx. No. People per sq. tt,i . // G <br />