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o <br /> l . SEWAGE 1,102 <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 /> � r <br /> Describe septic installation to b'e installed: <br /> 2 . WATER SUPPLY <br /> Is wat�C supplied try private well : Yes � No Is well proper: <br /> Yes No State deficiency : <br /> Does &Xisting or porposed use male tl)is well public water: Yes <br /> No 1/ 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.,- MOSGaUITO OR Y 'r-"' P2P�11T�AL <br /> State possible vector potential & necessary control : <br /> 5 . TQILET/BATH FACILI TS <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANI'I'ATU_U <br /> State any problems not previously noted: <br /> 3 . pOPI3L T � i�iITY <br /> Appx. No . People per sq. ml . _ _ <br />