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1 . aBEA , • <br /> Distance to Public Sewers nib Connection necessary: Yes No4�' <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 wa er supplied by private well : Yes 'Z No— Is well proper: <br /> Yes NoState deficiency : <br /> Does existing or porposed use make this well public water: Yes— <br /> No <br /> es <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 Ser ice Are$ Vo. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . EL.1L MOSQUITO OR YECTOR ECiTENTIAL <br /> State possible vector potential & necessary control .. 4vol <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : �!` Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> X- <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted: <br /> 8 . POPULATION DENSITY. ' <br /> Appx . No . People per sq . mi . �,�.P'�'�/.t�•<�� <br />