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1 . SEWAGE <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 /> Describe septic installation to 'be installed: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well : Yes iJo— 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 & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem-_ _ -4 . ELY, MOSQUITO OR VZaT__02_PL)fTNTT L <br /> State possible vector potentiitl ?z necessary control: <br /> 5 . TOI LET/BATH FACILTTES <br /> . <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . PREVIOUS QP RATI014 HISTn <br /> 7 . GENERAL A T Z&ZLQN <br /> State any problems not previously noted: <br /> S . POPULATION DE NSTTY <br /> Appx. No . People per eq. mi . <br />