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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 , _-xplain: <br /> Describe septic installation to be installed : <br /> 2 . MATER 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 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 /> Potential problem: ___ <br /> 4 . FLYL MOSQUITO OR V F^ s )MNTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TOTLET/BATH FACILITES <br /> No . & location existing : _ Additional <br /> facilities needed__ <br /> 6 . PREVIOUS OPERATION H LSTORY <br /> 7 . GENERAL SANITTA IOH <br /> State any problems not previously noted: <br /> 8 . POPULATION DENSITY <br /> ADDX. No . People Per sq. mi. <br />