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1 . 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 Nom Is well proper: <br /> Yes No State deficife-ney: _ <br /> Does existing or porposed use make this well public water : Yes <br /> No Sample of well water taken: Yes Nom 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 /> Potent-1al problem: <br /> 4 . ELLY-L MOSQ rITO OR Y Zi- E2MU1A <br /> State possible vector potential & necessary c ntrol: <br /> 5 . TQILET/BATH FACILI ' <br /> No . & location existing : — Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTc'iRY <br /> 7 . GENERAL SANITATION <br /> State any problems rjot previously noted: _ <br /> 8 . POPULATIONN-M '�' <br /> Appx. No . Peop/le per sq. mi . <br />