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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 installation to b installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes _ Flo_ 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: 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 /> � <br /> Potential problem: 51A0314ekt °1 ' <br /> 4. F ,Y, MOSQUITO RVP=OR POTFNTTA <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVIOUS OPERATION HISTORY, <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted: <br /> S . POPULATION DENSITY <br /> Appx . No. People per eq . mi . <br />