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f <br /> 1 . 5EWAGE <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 /> o 4 <br /> Describe septic installation to 'be installed: <br /> CIO <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 re <br /> Licenaed scavenger pick-up Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLI, MOSQUITO QR EQTOR PO C ENTIAL <br /> State possible vector potentiftl et necessary control : <br /> 5 . TQ .T/ ATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANITATION <br /> State any problem: not previously noted :- <br /> 8 . <br /> oted :_3 . POPULATION DEjST11 <br /> Appx. No . People per req . mi . <br />