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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 . MATER SUPPLY <br /> Is water supplied by private well : Yes iJo Is dell proper: <br /> Yes No State deficiency : <br /> Does existing or porposed use make this wEil public water: Yes <br /> Na Semple 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 EQTOR PQ'I'rNTTA , <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed _ <br /> 6 . PREVTO"S OPERATION Hj,Tn <br /> 7 . GENERAL SANTTATION <br /> State any problems not previously noted:- <br /> 8 . <br /> oted:_8 . 'O ILLATION DENiSTly <br /> Appx. No . People per cq. mi . <br />