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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes No_ <br /> Does existing septic system comply with Ord . 11549 : Yes No_ <br /> Unknown, If no, explain: <br /> Describe septip installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes -,<-- iJo Is well proper: <br /> Yes, No State deficiency: <br /> Doisting or porposed use make this well pu lic Water: Yes <br /> Noes�Sample of well water taken: Yes No V 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 . FjLy_L MOSQUITO OR VZ^TO PS'EENTIAL <br /> State possible vector potentit,l FA necessary control : Z9,10"L <br /> 5 . TOILET/BATH FACIL,TTES <br /> No . & location existing : .�! Additional <br /> facilities needed — _ <br /> 6 . PREVI00S OPERATION HISTORY- <br /> 7 . <br /> ISTOi7 . GENERAL SANITATION <br /> 'ION <br /> State any problems not previously noted- <br /> 8 . <br /> oted:s . POPULATSO14 DENSTIX <br /> Appx. No . People per 6q . mi . �a'i�/�✓�.��/�f"� �dE�r �: <br /> l ..S <br />