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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord. 41549 : 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 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 . EL L MOSQUITO OR EQTOR PO fJ NTIAL <br /> State possible vector potentiftl & necessary control : <br /> 5 . TQILET/BATH FACILITES <br /> No . & location existing: Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HIST <br /> 7 . GENERAL SAPJI_;r,J, TION <br /> State any problem; not previously noted : - <br /> 8 . <br /> oted : _s . POPUjATI014 DENSITY <br /> SI <br /> Appx. No . People per 6q. mi . <br />