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1 . MAGES <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 /> 2. WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes No State deficiency : <br /> Does existing or porposed 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 & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem- <br /> 4 . <br /> roblem:4 . FLY , MOSOUTTO OR VrQ TOR ECS' 2,NTIAL <br /> State possible vector potential necessary control: <br /> 5 . TOTLET/BATH FACILITES <br /> No . & location existing: Additional <br /> facilities needed <br /> 6. PREVTons OPERATION HT,sTnRy <br /> 7 . GENERAL SANTTAITON <br /> State any problems not previously noted: <br /> 8 . POPULATION DE STTY <br /> Appx. No . People per eq. mi . <br />