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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes_ No , <br /> Does existing septic system comply with Ord . 0549 : Yeses No_ <br /> Unknown If no , explain : <br /> Describe septic installation to be installed: <br /> 2 . HATER SUPPLY <br /> Is water supplied by private well : Yes -�L No_ Is well proper: <br /> Yes No_ State deficiency : <br /> Does�xisting or porposed use make this well public water: Yes <br /> No i Sample of well water taken: Yes_ No_ Date taken <br /> Results Additional information or comments 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes_ No_ Service Area No . <br /> Other proposed disposal method : <br /> Potential problem: <br /> 4 . ZL�L� MOSQUITO OR -YECTOR ECfrN� <br /> State possible vector potential & necessary control . <br /> 5 . TOTLFT/BATH FACILITES <br /> No . & location existing: Additional <br /> facilities needed <br /> 6 . PREVTOTIS OPERATION HISTORY <br /> SGS - C- i-, <br /> 7 . GENERAL SAtITTA'T'TON <br /> State any problems not previously noted : _ 'J& <br /> 9 . POPULATION DENSTTY <br /> Appx . No. People per sq . mi . Pis icl e c. , t cti� <br />