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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No <br /> Does existing septic system comply with Ord . 0549 : Yes ---' No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: ---- <br /> 2 . MATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes.4 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 . =. MOSQUITQ QB '" Q PC)f ENT TIAL <br /> State possible vector potentiftl & necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing : irrAdditional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HISTORY <br /> Z --- - <br /> 7 . GENE SAJITTA�,'ION <br /> State any problems not previously noted:! <br /> 8 . POPULATION DENSITY <br /> V <br /> Appx. No . People per 6q. mi . ���'����L����`�f✓-�f���,� <br />