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1 <br /> SEWAGF <br /> Distance to Public Sewers Connection necessary: Yes N&_ <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 SUPPL=I <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 Vell 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 . F-LLY-L MOSQUITO Q$ VZQ.- PSS MITIAL <br /> State possible vector potentiftl ?.c necessary control : <br /> 5 . TQILET/BATH FACILITES <br /> No. & location existing : — Additional <br /> facilities needed <br /> 6 . PREVIOi]S OPERATION HISTORY <br /> 7 . GENERAL SA1U!ATJ-(M <br /> State any problem: not previously noted: _ <br /> 8 . POPULATION DENSTI <br /> Appx. No . People per rq. mi . <br />