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1 . EWA , , <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 /> Z . 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 . MI, MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TQ1LET/BATH FACILIT-M <br /> No. & location existing : — Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION 1STORY <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted: - <br /> 8 . <br /> oted: _8 . POPULATION DENSITY <br /> Appx. No . People per sq. mi . <br />