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1 . SEWAGE -• <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 : Yeses No Is Well proper: <br /> Yeses No State deficiency : <br /> Doisting or porposed use make this well public water: Yes <br /> Noes e�Sample of well water tarsen: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . RBAGE & REFUSE <br /> Lensed scavenger pick-up: Yes No Service Area o. <br /> Others proposed disposal method: <br /> Potential problem: <br /> 4 . MOSQUITO OR VZ2­T-Q P.S)MEZ A , <br /> State possible vector potentiftl & necessary nt ( <br /> 5 . TO Q ' <br /> No . & location exist Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SA UTA'PTI�N <br /> State any problems got previouslyr,oted <br /> 8 . POPULATION D . I v <br /> Appx. No . People per rq . rr,i . <br />