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1 SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No <br /> Does existing septic system comply with Ord. 4549: Yes No <br /> Describe septic installation to be installed <br /> 2. WA'I'f'R SUPPLY <br /> Is wat,r supplied by private well: Yes v No Is well proper: Yes No <br /> Stec: deficiency: <br /> Does existing or proposed use make this well public water: Yes No ample of well <br /> water taken: Yes No �/>jate taken Results <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE <br /> Licensed scavenger pick-up Yes No Service Area No. <br /> Other proposed disposalmethod: <br /> Poteri i,1lerYis: S 1 <br /> r r J <br /> 4. FLY, MOSQUITO. OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control <br /> 5. TOILET/BATH FACILITIES <br /> No. & location existing: <br /> Additional facilities needed i— <br /> 6. PREVIOUS OPERATION HISTORY ` <br /> 4.1 <br /> eta <br /> 7. <br /> State any problems not previously noted: <br /> 8 POPULATION DENSITY <br /> Appx. number of people per square mile �� <br />