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r / <br /> 1. SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No <br /> Does existing septic system comply with Ord. 9549: Yes No <br /> Describe septic installation to be installed: <br /> 2. WATER SUPPLY � / <br /> Is water supplied by private well: Yes o Is well proper: Yes L�No <br /> State deficiency: <br /> , <br /> Does existing or proposed use make Ibis-well public water: Yes No+ G�ple of well <br /> water taken: Yes NoL--'Date taken Results <br /> 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 problems: <br /> 4. FLY MOSQUITO, OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5. TOILET/BATH FACILITIES <br /> No. & location existing: <br /> f ' <br /> Additional facilities needed <br /> 6. PRE US OPERATION HAkORY <br /> 7. GENERAL SANITATION <br /> State any problems not previously noted: <br /> 8. POPULATION DENSITY <br /> Appx. number of people per square mile <br />