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i <br /> 1 . SEWAGEi , <br /> Distance to Public Sewers Connection necessary: Yes N©_ <br /> Does existing septic system comply with Ord . #549 : Yes= No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: + J' vl ), <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes ,Y% No Is well proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make- this well public water: Yes <br /> Nom;_ 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 NQ: <br /> Licensed <br /> proposed disposal method: <br /> Potential problem: <br /> 4 . ZQUITO OR V 3 F-C)FENTIAL <br /> State pa"ible vector potential & necessary.-t:ontrol : <br /> 5 . TOILET/BATH FACILI7 <br /> No. & location existing: Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SAP3I'I' 1L <br /> State ap3 7 problems not previously noted: -- <br /> 8 . //Appx. NGPLTLAT�N <br /> o. People per sq. mi . <br />