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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 iso 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, MOSdUTTO OR VECTOR PO'[CNTTAL <br /> State possible vector potential R.c necessary control: <br /> 5 . TOTLET%BATH FACILITES_ <br /> No. & location existing: Additional <br /> facilities needed <br /> 8. PREVIOUS OPti ATIO ;[ HISTORY <br /> 7 . GENERAL SANITf TION <br /> State any problems not previously noted: <br /> S . POPULATION PEYSTTY <br /> Appx. No. People per sq. mi. <br />