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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No— <br /> Does existing septic system comply with Ord. 35�,9J Yeses_ No� <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is wa r supplied by private well : Yes No Is well proper: <br /> Yes--!L- No State deficiency : <br /> Doisting or porposed use make thi3 well pub is Water: Yes <br /> Noes�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 . FLYS MOSQUITO OR V ^.TO pSf TIEI�� <br /> State possible vector potential necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing : _ Additional <br /> facilities needed _ <br /> 6 . PREVTOnE OPERATION <br /> 7 . GENERAL SA1UjA LI ON <br /> State any problems. riot previously noted :_ <br /> 8 . EO > 1 ,ATION hrUTTY <br /> Appx. No . People per Bq . mi . <br />