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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 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 & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. ELI.- MOSQUITO OR EZT(-) P2fTiNT AL <br /> State possible vector potentiftl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: — Additional <br /> facilities needed M _ <br /> 6 . PR .VIOPE OPERATION HISTORY <br /> 7 . GENERAL SAiU'r,ATTON <br /> State any problems not Previously noted : - <br /> 8 . <br /> oted : _3 . 20PULATION DFt STTi <br /> ADnx . No . Peonle Der sq . mi . <br />