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1 <br /> J <br /> 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 Na 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 tarsen: 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 . ZLI�_ MOSQUITQ OR VMO M) I <br /> State possible vector potentiFtl & necessary control : <br /> 5 . TOILET/BATH FACUTTES, <br /> No . & location existing: _ Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HIST�x <br /> 7 . GENERAL SA1111A ' ON <br /> State any problems not previously noted: _ <br /> 8 . POPULATION DEiJi <br /> Appx. No . People per eq. mi . <br />