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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, explain: <br /> Describe septic installation to be installed: <br /> 2 . WATER 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: Yee <br /> No Satmple 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 . MOS <br /> QUITO OR 1ECTOR VECTORZ2fanT.T_AIL <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACTLITE5 <br /> No . & location existing: _ Additional <br /> facilities needed —_ <br /> 6 . PRFVTofis npEgATIO,IIj;,TDR_X <br /> 7 . GENERAL SANTTATTON <br /> State any problems lint previously noted : <br /> S . pO, PII,ATTON DEtd,TIY <br /> Appx . No . People per sq. mi . <br />