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1 . aEWAGE <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 /> Describe septic installation to be installed: <br /> Z . WATER SUPPLY <br /> Is water supplied by private well : Yes No Ir6 well poper: <br /> Yes No State deficiency: <br /> Does existing or purposed use make this well public water : Yes <br /> No Sample of well water -taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REEUSE <br /> . Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed`, disposal method.- <br /> Potential <br /> ethod:Potential problem: <br /> 4 . ELI, MOSQUITO OR1 i PS�'i'�.I UL. <br /> State possible vector potentiftl & necessary control : <br /> 5 . TQILET/BATH FACILjj.jZ <br /> No . & location existin _ __.. Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTOL 7 <br /> 7 . GENE R&L—ZAMIATIM <br /> State any problems not previouAay noted : -- <br /> 8 . <br /> otedS . <br /> Appx. No . People per sq. mi ._ <br />