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1 . S E WAGF� <br /> Distance to Public Sewers /i,; Connection necessary: Yes No <br /> Does existing septic system comply with Ord . 31549 : Yes No_ <br /> Unknown If no, explain : <br /> Describe septic installation to 'be installed: <br /> 2 . WATER SUPPLY D- u&-ce� l <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.X Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Servi-ce Area No . <br /> Other proposed disposal method: <br /> Potential problems <br /> 4 . MI—MOSQUITO OR VEMORi'j'rN Al <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACILI ' S <br /> No . & location existing : _ Additional <br /> facilities needed <br /> 6 . PREVTO02 O .RATION HISTORY <br /> 7 . GENERAL SANITATION <br /> State any problem: not previously noted:_ <br /> 8 . POPULATTOt4 DENSTTY <br /> Appx . No . People per Gq. mi . <br />