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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord. $1549 : 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 porposed 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 . =�_ MOSQUITQ OR V QTO PC'fLjjZIALL <br /> State possible vector potentiftl & necessary control: <br /> 5 . TQILET/BATH FACILITES <br /> No . & location existing: _ Additional <br /> facilities needed _ <br /> 6 . PREVI002 OPERATION HISTO r <br /> 7 . GENERAL SANI,r '1. TION <br /> State any problems not previously noted: - <br /> 3 . <br /> oted: _8 . POPULATIQ14 DFt `'T v <br /> Appx. No . People per rq . mi . <br />