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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 stallation to 'be installed: <br /> Z . 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" x ;,, <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem : <br /> 4 . MOSQUITO OR V :QTQ ZCi'j'r MAL <br /> State possible vector potentiitl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . ec location existing : _ Additional <br /> facilities needed _ <br /> 6 . PREyionrS OPE_R.ATIIOid HISTO) i <br /> 7 . GENERAL SAPUT '1.A ,ION <br /> State any pro'blemS not previously noted :_ <br /> 3 . POPULATION DENSITY <br /> Appx. No . People per rq . rr,i . <br />