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1 . EEWAGE� <br /> Distance to Public Sewers Connection necessary : Yes No_ <br /> Does existing septic system comply with Ord . 0549 : 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 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 . <br /> roblem:4 . FAL MOSQUITO OR VZ^.TO i'frNTjAL <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : — Additional <br /> facilities needed _ <br /> 6 . PREVTO(1,5 OPERATION HISTORY- <br /> 7 . GENERAL SANITATION <br /> State any problem: not previously noted : _ <br /> 8 . FJT1PI TON 3F" T v <br /> Appx. No . People per sq. mi . <br />