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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 porposed usc make this well public water: Yes <br /> No Sample of well water tarsen: 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, MOSQUITO OR Vr�TQ2 p,�i'j'J11�TIAL <br /> State possible vector potentiitl. & necessary control: <br /> 5 . TOILET/BATH EACIL11M. <br /> No . & location existing: Additional <br /> facilities needed - <br /> 6 . PREY1002 OPCRATIGU HISTORY <br /> 7 . GENERAL SAt►TIATTON <br /> State any problems not previously noted : <br /> 8 . POPULATIOtj DENSITY <br /> Appx. No . People per 3q. mi . <br />