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1 . 5FWAGE <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 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 <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. =L - MOSQUITO QR VZ .TO ELUXMT <br /> State possible vector potentiFll & necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed _ <br /> 6 . PREVTO05 OPERATION HISTt7 r <br /> 7 . GENERA SANI'r 'lp LQ <br /> State any problems not previously rioted:_ <br /> 8 . EOPULATI014 DENj,,M <br /> Appx. No . People per rq. mi . <br />