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s <br /> 1 . SEWAGF <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . 11549 : 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 dell proper: <br /> Yes 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 /> 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 . ZLLYL MOSQUITO QRy QTO E i'fLaT_TAa1 <br /> State possible vector potentiFtl & necessary control : <br /> r'j () <br /> 5 . TOI-LET/BATH FACILITES <br /> No . & location existing: _ Additional <br /> facilities needed nie-FL. cooEM 3 <br /> 6 . PREVI0172 C; ER.ATION H STS r <br /> 7 . O RN RAL sAriI'r.ATI() <br /> State any problems riot previously noted- <br /> S . <br /> oted:S . M ' ILATION DENSITY <br /> Appx. No . People per 6q . m i. . <br />