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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---Z If no, explain: <br /> De cribe septic installation to be ins alled: fi° <br /> 2 . HATER SUPPLY <br /> Is water supplied by private well : Yes No �K 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 /> Result: 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 . ELY, MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH EACILITES <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 , GENERAL SANITATION <br /> State any problems not previously rioted : <br /> 8 . POPULATION DENSITY / <br /> A p p x. No . People per sq . mi . ">Z' -f6'o <br />