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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes No ') <br /> Does existing septic system comply with Ord. #549 : Yeses 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 �'` No Is well proper: <br /> Yes. No State def iciency : _ <br /> Doesxist ' g or porposed use make this well public water: Yes <br /> NoSample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> . Licensed scavenger pick-up: Yes k No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . =,,- MOSOUITQ OR YZCTCa PSVT N`i IAL <br /> State possible vector potentiftl & necessary control : ��1f <br /> 5 . TQILETZBATH FACILIMS <br /> No . & location existing : ,� _ Additional <br /> facilities needed <br /> 6 . PREVI/OUS OPERATION HZT�iRY <br /> 7 . GENERAL SANI'LU101. <br /> State any problem: not previously rioted: <br /> 8 . POPULATIONNLE. =Y_ ' <br /> Appx. No . People per sq . mi . <br />