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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---- <br /> o_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 . EI ��ITt"J OR y '� y PS�'I'F.NTIAL <br /> State possibly: vector potenti&I & necessary control : <br /> 5 . TA LI ETIBATH FACILI`IM <br /> No. & location existing : ___.. Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HISTtY <br /> 7 . GENERAL SANI'TATION. <br /> State any problems not previously noted : - <br /> 8 . <br /> oted : -8 . POPULATIQN DENSITY <br /> Appx . No . People per sq. ml . _ <br />