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1 . SFWAU <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 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. FLY. MOSQUITO OR VrQ TOR PO'rrt1�AL <br /> State possibly: vector potential FA necessary control: <br /> 5 . TnTLET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . PREVInUs opgRATInN HISTnRY <br /> 7. GENERAL SANTTAT ON <br /> State any problems not previously noted: <br /> S . POPULATION DEYSTTY <br /> Appx, No . People per sq. mi . <br />