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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 /> L-2 OdA— <br /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes :Z� 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 yECTOR POTENTIAL <br /> State possible vector potential & necessary control : <br /> i <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing : Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTO �\ <br /> 7 . GENERAL SANITATION <br /> State any problems not previously n ted: <br /> S . POPULATION DENSITY <br /> Appx. No . People per sq. mi . <br />