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1. SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No— <br /> Does existing septic system comply with Ord, #549 : Yea 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 Hell proper: <br /> Yes No State deficiency: <br /> Does existing or porpoeed use make this well public Water: Yes <br /> No 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 /> Ether proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSOUTTO OR VMOTOR EC)TENTIAL ` <br /> State possible vector potential & necessary control: <br /> 5. TOILET/BATH FACTLITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. EREVIOUS OPERATIQUO <br /> 7 . GENERAL SANITATION <br /> State any problems not Preciously noted: <br /> 8 . P0P[ILATTnN nF'NSTTy <br /> Appx. No. People per .eq. mi. <br /> i <br /> I <br /> r <br />