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1 . S •WA E <br /> Distance to Public Sewers Connection necessary : Yes— No_ <br /> Does existing septic system comply with Ord . 11549 : Yes— No_ <br /> Unknown If no, explain: <br /> ,at <br /> KC I/t <br /> f S y�j <br /> Describe septic installation o be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes ilo_ Is well proper: <br /> Yee_ No—� State deficiency: <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 & REFUSF <br /> Licensed scavenger pick-up : Yes— No_ Service Area No . <br /> Other proposed disposal method! <br /> Potential problem: <br /> 4 . MnSCJUITn ORI ZaToRESIrauzTAu <br /> State possible vector potential & necessary control : <br /> 5 . TnILET/BATH EACILITE5 <br /> No . ez location existing : — Additional <br /> facilities needed <br /> 6 . PREVIOUS nPERATION JETnF'Y <br /> 7 . GENERAL SAtITTATION <br /> State any problems nrDt Prevlou:;ly noted : _ <br /> 9 . PO 1j,ATION r)EiJSTTY <br /> Appx . No . People per sq . mi . <br />