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1 . SEWAGF <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 Na 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 . FILL MOSQUITO OR VEQTOR POr BjIAL <br /> State possible vector potentiFtl necessary control : <br /> 5 . TQTLET/BATH FACILITY'S <br /> No . & location existing: _ Additional <br /> facilities needed _ <br /> 6 . PREVIOU OPERATION HISTn r <br /> 7 . GENERAL aANITA'1'TON <br /> State any problems not Previously noted : _ <br /> S . EQPIILATION DENSTTy <br /> Appx. No . People per rq . mi . <br />