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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 tI)is well public water: Yes <br /> Na 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 . FLY,- MQSQUITQ OR VECTOR FO r ,NTIAL <br /> State possible vector potential. & necessary control : <br /> 5 . TQILET/BATH FACILITa <br /> No. & location existing: __ Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANIM`],'T_lfr] <br /> State any problems not previously noted: ._,_ _ <br /> 3 . �OPLIT,ATION TIENSITI <br /> Appx. No . People per sq. mi ._ <br />