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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 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 . E11� MOSQUITO OR_YZ:Q ' PST=SIAL <br /> State possible vector potentiFtl. & necessary control - <br /> 5 . JI_L_F /BATH FACILI7 <br /> No. & location existing - - Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HIST M <br /> 7 . GENERAL SANI7'A'IM <br /> State any problems not previously n()ted : _ — <br /> 8 . POPUL, (1 UE=Y <br /> Appx. No . People per sq . iril . _— <br />