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1. SEWAGE l <br /> Distance to Public Sewers "}I Pr Connection necessary Yes No <br /> Does existing septic system with Ord 4549 Yes No <br /> �a,..wf 7�-rYo �tffxcl�eo( <br /> Describe septic installation to be installed- <br /> 2. WATER SUPPLY <br /> Is water supplied by private well. Yes No Is well proper: Yes No <br /> State df'�iic�iency <br /> Does existing or proposed use maa this well public water: Yes No ✓ ample of well <br /> water taken Yes No ✓ Date taken �� _ Results ' <br /> Additional information or comments: <br /> 3 GARBAGL & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> PO i-'dL;_tLl problems: <br /> 4 FLY. MOSQUITO. OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control. <br /> 5 TOILET/BATH FACILITIES <br /> No. & location existing: <br /> Additional facilities needed <br /> 6. PREVIOUS OPERATION HISTORY <br /> 7. GENERAL SANITATION <br /> State any problems not previously noted <br /> 8 POPULATION DENSITY <br /> Appx. number of people per square mile <br />