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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes_ No_ <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 : 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 . Ei�L� MOSC)UITO ORy 71^TO, POfEUTIA:a <br /> State possible vector potentir,l & necessary control : <br /> 5 . TOILET/BATH FACIL>`ES <br /> No . & location existing : _ Additional <br /> facilities needed---- <br /> 6 . <br /> eeded —_6 . PREVTOIIS OPLR,ATTQ HLSTO , <br /> 7 . GENERAL SAPITT 1.A ION <br /> State any problems not previouol.y noted :- <br /> 3 . <br /> oted :_3 . pnPU ,ATION pENSTTY <br /> Appx . No . People per sq . mi . <br />