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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 ineta led: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No:!L 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 TOR POTENTIAL <br /> State possible v ctor potentihl & necessary control : <br /> 1 <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANITATION <br /> ' l <br /> State any problems not previously noted : _ <br /> 8 . POPULATION DENSITY <br /> Appx. No . People per sq. mi . <br />