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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . 41549 : 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 ilo Is dell proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make this well public Water: Yes <br /> No 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 . =.,- MOSQUITO OR V !^TQ! E2r1 1� TIAL <br /> State possible vector potential PA necessary control - <br /> 5 . <br /> ontrol :5 . TOILET/BATH FACILITES <br /> No. & location existing: _ Additional <br /> facilities needed _ <br /> 6 . PREVTO02 OPERATION HISTORY <br /> 7 . GENERAL SAijIT `1,A ' -(—) <br /> State any problems do t previously noted: _ <br /> 8 . pOH ' iLATIONd DEN `,TTY <br /> Appx. No . People per 6q . mi . <br />