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1 . SEWAGE <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 /> Z. 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 /> No Sample of well water taken: Yes Na 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 . FLY.,_ MQSQUITQ OB yECTOR PQfjB=Au <br /> State possible vector potentiftl ez necessary control: <br /> 5 . Z4ILFT/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed _ <br /> 6 . PRF�YIQUS QPERATIQN HISTngy <br /> 7 . ORNERAL SANI'r,A]'IQN <br /> State any problems not previously noted :_ <br /> 8 . POPULATT_QN DFN,UTY <br /> Appx. No . People per req. mi . <br />