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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes Nom <br /> Does existing septic system comply with Ord . #549 : Yes No_ <br /> Unknown If no, explain: <br /> Descr be�sept c installation to installed: <br /> 2 . WATER SUPPLY <br /> Is :z7No_ <br /> r supplied by private well : Yes -4No Is well proper: <br /> YesState deficiency : <br /> Does existing or porposed use make this well puYJic Water: Yes <br /> Nom _ 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 . ELLy_. MOSQUITO OR VEOR_E _'fj 1.T <br /> State possible vector potential tc necessary control: ;� <br /> 5 . TQILrT/BATH FACILITES <br /> No . & location existing ! — Additional <br /> facilities needed — - <br /> 6 . PRFVIOU2 OPERATION HTSTORY <br /> 7 . GENERAL SANTT TION <br /> State any problems not: previously noted: <br /> 8 . POPULATION DENSITY <br /> Appx • No . People per rq . mi . <br />