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1 . S.FWAGR <br /> Distance to Public Sewers Connection necessary: Yes No - <br /> Does existing septic system comply with Ord. 11549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> N"Q <br /> 2. WATER SUPPLY <br /> Is w er supplied by private well : Yes —20-� No_ Is well proper: <br /> Yee No_ State deficiency: <br /> Does existing or porposed use make this well public water: Yes <br /> No= Sample of well water taken: Yes_ No�\Z—' Date taken <br /> Results Additional information or comments <br /> 3. GARBAGE & REFUS . <br /> Licensed scavenger pick-up: Yes-2- No_ Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR VECTOR PQ'L NTTA <br /> State possible vector potential do necessary control : <br /> 5 . TO .F.T/BATH FACTLITES /p1 Additional <br /> No. & location existing: <br /> facilities needed _ <br /> 6 . PREVIOUS OPERANT"ION HISTORY / <br /> 7 . GENERAL SANIT '1-q ION <br /> State any problems not previously rioted: v <br /> 9 . POPULATION DENSITY / <br /> Appx. No . People per sq. mi. 1N <br />