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1. S&1AG <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 installation 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 token: Yes_ 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 VRQTOR FOrENTTA , <br /> State possible vector potential & necessary control: <br /> 5. TOILET/BATH FACILITES <br /> No. ec location existing: Additional <br /> facilities needed —_ <br /> 6. PRF.VTOUS O .R.ATION HISTM <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted:- <br /> 8 . <br /> oted:_9 . POPULATION DF•NSTTX <br /> Appx. No. People per act. mi. <br />