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1 . SAG <br /> Distance to Public Sewers Connection necessary: Yes No-- <br /> Does <br /> o_Does existing septic system comply with Ord . 0549 : 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 /> Na Semple 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 Off; VEQTQR POfENTTAL <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: — Additional <br /> facilities needed _ <br /> 6 . PREV1003 OPERATION HISTngY <br /> 7 . OENERA L SAIJIT,ATION <br /> State any problems not previously noted: <br /> 3 . POPULATION DE rI y <br /> Appx. No . People per eq . mi . <br />