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J <br /> i . 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 /> Z. WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes No State deficiency: <br /> Does existing or porpased 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 & RRF(JSR <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem:__- <br /> 4. <br /> _4. FLY. MOSQUITO OR Vr_OT013 POTENTTAL <br /> State possible vector- potential F.c necessary control: <br /> 5 . TO T L .T/BATH FACILITE3 <br /> No . & location existing: Additional <br /> facilities needed <br /> 6. PREVIOUS_ rP RRATTnN HraTOB.Y <br /> 7. GENERAL SANTIATTOM <br /> State any problems not, previously noted: <br /> S . POPUL.ATION DENSTly <br /> Appx . No . People per eq . mi . <br />