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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes No --- <br /> Does <br /> oTDoes existing septic system comply with Ord . #549 : Yes No= <br /> Unknown If no, explain : <br /> Describe septic installation to be installed : <br /> Z . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes No—_ State deficiency -0"-' OwAfJ°'� <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 informationor Commen-ts <br /> 3 . GARBAGE & REFUSE O/� <br /> Licensed scavenger pick-up: Yes No_, Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . F,ILI, MOSQUITO OR YT';m Q PS)=I L <br /> State possible vector potential & necessary control - <br /> 5 . <br /> ontrol -5 . 0 ET/BATH FACILI'II <br /> No . & location existing - - Additional <br /> facilities needed <br /> 6 . PREVIOUS OPyRATION HISTORY <br /> 7 . GENERAL SAPtI=-M <br /> / y <br /> State any problems not previously noted : —e,' <br /> 8 . POP UL A I1��IM;T •y <br /> Appx . No . People per sq. mi. <br />