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1. SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . 0549 : 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 Na State deficiency : <br /> Does existing or porposed use make this wEil 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 VE^.TO ZC)M <br /> State possible vector potentiftl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing : _ Additional ` <br /> facilities needed _ <br /> 6 . PRFV I Oil a opEgAT I ON H I STngy <br /> 7 . GENERAL SA1U TION <br /> State any problems not Previour;l- <br /> y noted: _ <br /> 3 . E'OPULATIO14 DENSTTV <br /> Appx . No . People per 6q . mi . <br />