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1 . SEWAGE t <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 SUEUIY <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 1. Date taken <br /> Results Additional information or comments <br /> 3 . REFUSE <br /> . Li nsed scavenger pick-up: Yes No Service Area No . <br /> Othe'V proposed disposal method: <br /> Potential problem: <br /> 4 . =.,- MOSQUITQ OR y O P-C)L3'NTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TQILET/BATH 'ACIT UES <br /> No. & location existing': _ Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANIM�,'N. <br /> State any prol)lems not previou-sly noted: _—`— <br /> 8 . POP t AT I O aEj a <br /> Appx. No . People per sq. mi ._ <br />