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1 . SWAGE <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 p-.ck--up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem- <br /> 4 . <br /> roblem:4 . FLY. MOSQUITO OR V - T02 PO'rENTlAL <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . PREVIORS OPERATI014 HL'=j <br /> 7 . GENERAL. S611T CATTON <br /> State any problems not previously noted: <br /> 8 . POPIILATIQN DENSITY <br /> Appy. No . People per sq. mi. <br />