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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 /> Nom_ Sample of well water taken: Yes_ No_ Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yeses No_ Service Area No. <br /> Other proposed disposal method: <br /> Potential problem : <br /> 4 . ELY . MOSQUITO ORvNCTOR psr �.Nr TIAL <br /> State possible vector potential & necessary control : - - r <br /> 5 . TOILET/BATH FACILiJTES oy <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVTOUS OPERATION H STORMY/ <br /> GAG t /J f�AoQQ�,f ,l7/.fT.l/mac/7 mor C f — �l�il'i['i/S�il.� <br /> 7 . GENERAL SANTTATTON <br /> State any problems not previously noted: <br /> 9 . POPULATION DENSITY <br /> Appx . No . People per eq . mi. <br />