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1 . SEWAGE <br /> Distance to Public Sewers Oonnection necessary: Yes N6 <br /> Does exi ti septic system comply with Ord. #549: Yes No_ <br /> Unknown no, explain: <br /> go V-J- .Z CLQ ' $ <br /> De ribP <br /> I <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : YesNo Is well proper: <br /> Yes NoState def iciency: L6A c ✓✓ i k d G� ya J f is . ; Voe <br /> OF 0 <br /> Does existing or porposed use make this well pub}c water: Yes <br /> No Sample of well water taken: Yes No / Date taken <br /> Results Additional information or comments ;LAp,,,Z a j S A <br /> a, <br /> 3 . GARBAGE & REFUSE 04; S <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLY . MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: Additional <br /> facilities needed <br /> 4 <br /> 6 . PREVIOUS OPERATION HISTORY jr <br /> e4 r <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted : <br /> 8 . POPULATION DENSITY <br /> Appx. No . People per sq. mi . <br />