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1' SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes_ NoY <br /> _� <br /> Does existing septic system comply with Ord. 05,4Q : Yes— No_ <br /> Unknown If no, explain: r��`��i <br /> Desc ibe septic installation to be installed: few wi/�ii'1�1a <br /> 2. WATFR SUPPLY <br /> Is water supplied by private well : YesNo.�,Is we7,1 prop�r- <br /> Yes_ No_ State deficiencY: s`'�� ��s��s <br /> Does existing or porposed use make this well public water: 'les <br /> No_ Sample of well water token: Yes_ Nom 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 VE,^.TOR PO"LUTTA , <br /> State possible vector potential FA necessary control: <br /> 5 . TOILET/BATH FACILTTF.S <br /> No. ez location existing: 4A� Additional <br /> facilities needed <br /> 6. PREVIOUS f PRRRATIQN HISTORY <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted: <br /> 3 . POPULATION DENSITY <br /> APPx . No. People per sq. mi. 6PiC�L �/-�c� <br />