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1 . SEWAGE <br /> Distance to Public Sewers / Connection necessary: Yes_ Not <br /> Does existing septic system comply with Ord . 0549 : Yes_ No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> 2 . 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: 'les <br /> No�,�/Sample of well water taken: Yes_ No-Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & BEFUSE <br /> Licensed scavenger pick-up: Yes No_ Service Area No. <br /> Other proposed disposal me;' ,64 � <br /> Potential problem:-- <br /> 4 . FLY . MOSnUITn OR yFCTOR POTENTr L <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH FACTLITFU <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PRRYTOUS Qj!KRATT0N HISTDRX <br /> or <br /> 7 . GENERAL SANITATTON <br /> State any problems not previously noted : <br /> 3 . P0j!ULATI0N I1F" ST v <br /> Appx• No . People per sq . mi . <br />