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1 . SEWAGE <br /> Distance to Public Sewers0r. • Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . #549 : Yes No— <br /> Unknown <br /> o_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 deficiency: <br /> Does existing or porposed use make this well public water: Yeses_ <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments moi ' <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. MOSQUITO OR VC- TOR PO'rENTTAL <br /> State possible vector potential ek necessary control: ��. <br /> 5 . TQTLET/BATH FACILITES <br /> No. ek location existing: ' Additional <br /> facilities needed <br /> 6. PREEVTOnS OPERATION HTSTORY <br /> 7 . GENERAL SAITTI ITON <br /> State any problems not previously noted: �cOL <br /> 3 . POPULATION DEL SY ITY <br /> APpx. No . People per sq. <br />