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1 . S EWA ,F <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . 11549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to *be installed: <br /> Z. 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. MOSOUTTO OR V ,;TOR POTS ,NTIAL <br /> State possible vector potentiftl AA necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: _ Additional <br /> facilities needed <br /> 6. PR yTonS n RRATTON HISTdRY <br /> 7. GENERAL SAIT IAT _ON <br /> State any problems not previously noted: <br /> 3 . POPULATION DEN STTY <br /> Appx. No . People per aq. mi. <br />