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I . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes No_ <br /> Does existing septic system comply with Ord . #549 : 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 dei'icieney : _ <br /> Does existing or porposed 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 /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLY, MOS QUITO OR YEQTOR 02MMAII <br /> State possible vector potential & necessary control : <br /> 5 . TQJ-LFUBATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed ----- <br /> 6 . PREVIOUS QPERATJM__HJ_ETDRy <br /> 7 . GENERAL SANI1AJ_M <br /> State any protlems not previously noted: <br /> 8 . POPULATIQN DETMIT-1 <br /> Appx . No . People per sq . mi . -__ <br />