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{ <br /> I , <br /> I ` <br /> 10 <br /> Q _ r� T� <br /> 1. SEWAGE L/ ia- <br /> Distance to Public Sewers Connection necessary.- Yes No <br /> ry <br /> Does existing septic system comply with Ord. #549: Yes Na <br /> Describe septic installation to be installed: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes No 1/ Is well proper: Yes No <br /> State deficiency: <br /> Does existing or proposed use make this well public water: Yes No Sample of well <br /> water taken: Yes No Date taken Results j <br /> Additional information or comments: 4 be z <br /> 3. GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problems: <br /> 4. FLY, MOS UITO. OR VECTOR POTENTIAL <br /> State possible vector potential & ne essary control: <br /> 5. TOILET/BATH FACILITIES <br /> No. & location existing.- <br /> Additional <br /> xisting:Additional facilities needed <br /> b. PRE OUS OPERATION WSTORY <br /> J <br /> 7. GENERAL SANITATION <br /> State any problems not previously noted: <br /> 8. POPULATION DENSITY <br /> Appx. number of people per square mile <br />