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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-L-­ No_. <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 1Z I <br /> 2 . WATER SUPPLY <br /> Is wz4ter supplied by private well : Yes No Is well proper: <br /> Yes i, No State deficiency : <br /> Does.. existing or porposed use make this well public water: Yes <br /> No Sample of well water tarsen: Yes No Date taken <br /> Resu is 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 . ELLY_L MOSQUITQ O$ V ,^.TOS PC)f.I;2T?AL <br /> State possible vector potentiitl 8.c necessary control : <br /> 5 . TSILET/BATH FACILITES <br /> No . & location existing: — Additional <br /> facilities needed _ <br /> 6 . PREVIOf15 OP gATIIn_i1 H � (�FY <br /> ry <br /> �- � <br /> 7 . GENERAL SANIT '1,A ' -(—) <br /> State any y problem~ riot I previouSl y noted , — <br /> Z <br /> 3 . pn a 1jATIOt1 DE ` <br /> Appx. No . People per sq . mi . <br />