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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes_ Nom <br /> Does existing septic system comply with Ord . 11549 : Yes_ No_ <br /> Unknown If ao , explain: <br /> Desc ik_ septiQ installation to be install d: <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: Yeses <br /> No Sample of well water taken: Yes_ No_ Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUS ! <br /> Licensed scavenger pick-up: Yes_ No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLYS MOSQUITO OI�_YECTOR PSiPr.N__ LIAL <br /> State possible vector potential & necessary control : Py<< <br /> 5 . TOILET/BATH FACTLITFS <br /> No . & location existing : _ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANITA11 ] / <br /> State any problems not previously noted: �o�r <br /> s . Appx . No . People <br /> p ����1���e� <br /> Appx . No . People per sq . mi . <br />