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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes_ No_ <br /> Does existing septic system comply with Ord. 41549 : 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: Yes <br /> No Sample of well water taken: Yes_ No_ Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & R •FUSS <br /> Licensed scavenger pick-up: Yes_ No_ Service Area No. <br /> Other proposed disposal method: <br /> Potential problem : <br /> 4 . Pj, MOSQUITO OR V Z.aTO Z2MRT?AT4 <br /> State- possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : _ Additional <br /> facilities needed —_ <br /> 6 . PREVIOUS OPERATION L,5TOFY <br /> 7 . GENERAL SANITATION <br /> State any problems riot previously noted : _ <br /> 8 . POPULATION DENSITY <br /> Appx . No . People per sq . mi . <br />