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1 . SEWAGE �. <br /> Distance to Public Sewers L L Connection necessary : Yes No_ <br /> Does existing septic system comply with Ord . #549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe stie installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water uppl 'iedby private well : Yes NoX_ Is well proper: <br /> Yes No Qtate deficiency : <br /> Does existing r porposed use make this well public water : Yes <br /> No Sample o ell water taken: Yes No Date taken <br /> Results Add Tonal 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 . FLYS MOSQUITO OR VECTOR PS►MN'II_AL <br /> State possible vector potential & necessary control : <br /> 5 . TSIILET/BATH FA=TL ,a <br /> No . & location existing : __.. Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTca <br /> 7 . GENERAL SANI'ZA'IQU <br /> State any problems not previously noted: - <br /> 8 . <br /> oted: _S . POPULATIQN DEk'J=j <br /> Appx. No . People per sq. mi . _ <br />