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1 . SWAGE <br /> Distance to Public Sewers Connection necessary : Yes_ No_ <br /> Does existing septic system comply with Ord . 11549 : Yes— No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> Z . 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 & RFFUSF. <br /> Licensed scavenger pick-up: Yes— No_ Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . = MOSQUITO OR —VECTOR ZC)rLH _IA,TL <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FLaLLjTES <br /> No . & location existing: _ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPLRATTa STD= <br /> 7 . GENERAI SANTTATION <br /> State any problems nob previously noted : <br /> 8 . 20I[ATTON DEMSTT 'Y <br /> Appx . No . People per sn• mi . <br />