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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 /> 2 . WATER SUPPLY <br /> Is water supplied by private well : 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 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 . =Lr O OR_YECTOR PC)'=, ' IA. <br /> State possible vector potential & necessary control : <br /> 5 . TQLI ET/BATH FAC,ILI71a <br /> No . & location existing : ___ Additional <br /> facilities needed _- <br /> 6 . PREVIOUS OPERATION EMT= <br /> 7 . GENERAL SANI'TA T_�M. <br /> State any prol-)lems not previously noted: ---- <br /> 8 . POPULATION_M=_y <br /> Appx. No . People per sq. rrii . ._ <br />