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1 . 5EWAGE <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 installati n to 'beinstalled: <br /> 1l e- <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes u iia Is well proper: <br /> Yes_ /V No State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> Nom 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 VEQTQR aLffl iT.IAL <br /> State- possible vector potentiFtl & necessary control : <br /> 5 . TOILET/BATH I'AC,ILITES <br /> No . & location existing: Additional <br /> facilities needed _ <br /> 6 . PREVTOnS CpEgATInt4 HISTORY <br /> 7 . GENERAL SANI'r_AM ON <br /> State any problems not previously noted: _ <br /> 8 . POPULATION DEQJ <br /> Appx . No . People per rq. mi . i`; '`. <br />