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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 instillation 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 /> No Sample of well water taken: Yeti 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 . FLY, MOSQUITO OR VECT2R—ECUE TIAL <br /> State possible vector potential & necessary control : <br /> 5 . T?tILETlBATH FAC I ITS <br /> No . & location exiltirig : —_ Additional <br /> facilities needed ___ _ __- <br /> 6 . PREVIOUS OPERATION HI,2T'Ct ' <br /> 7 . GENERAL SAKI' `lr -01. <br /> State any proi)lems no 1. previously noted.: .— _ <br /> 8 . POPULATION DENSIT-Y <br /> Appx . No . People per f:%:i . mi .- <br /> _ --- <br />