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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 . 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 /> Na Sample of well water taken: Yes No Date taken <br /> Results Additional information or comment's <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 YEQTQR 'AMENTIAL <br /> Stare possible vector potential & necessary control : <br /> 5 . TQILET/BATH FACILITY <br /> No. &. location exiting : ___ Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION H.I,aMB- <br /> 7 . GENERAL SANI'rA L01. <br /> State any problems fiat previously noted: — _ <br /> 3 . FOP LATIQN DEKIT-1 <br /> Appx. No . People per sq. mi .- <br />