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' r <br /> ' <br /> 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. NATER 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. FLY. MOSQUITO OR YFQTnR PO'rENTTAL <br /> State possible vector potentiztl & necessary control: <br /> 5 . TQTT,ET/BATH FACTL ITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVIOUS OPERATION HISTORY <br /> 7. GENERAL SANTON <br /> State any problems not previously noted: <br /> 3 . POPULATI014 DENSTTY <br /> Appx. No. People per eq. mi. <br />