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M <br /> 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 /> (� a <br /> 2 . WATER SUPPLY <br /> Is w�ter supplied by private ;cell : Yes No Is well proper: <br /> Yes No__ State deficiency: — <br /> Does existing or purposed use make this well public water: Yes— <br /> No—sample <br /> esNosample 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 . FLY. LMOSQUI,TO OR Y 'fMQ�MUB TIAL <br /> State possible vector potential & necessary control : <br /> 5 . T LET/BATH F CI .ME <br /> No. & location existing:_ Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION <br /> HISTORY—Ll y� <br /> 7 . GENERAL SANITAT ON <br /> State any problems not previously noted- _ <br /> 8 . EOPULATIQN DEidF2=j <br /> Appx. No . People per sq. mi ._ <br />