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1 • SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes_ No_ <br /> Does existing septic system comply with Ord. 0549 : Yes_ No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes _ ijo_ 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 . ELY MnSc,UITn Og VZCTn ZC)rLBTIAu <br /> State- possible vector potential & necessary control : <br /> 5 . TQILET/BATH FACILITES <br /> No . & location existing : _ Additional <br /> facilities needed —_ <br /> 6 . PR .VInnS OPERATION HI 1'n <br /> 7 . GENERAL SAtIT'-rA TON <br /> State any problems not prevlously noted: _ <br /> 3 . POPULATION DE.LJSTTY <br /> Appx . No . People per sq . mi . <br />