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1 • SEWAGE <br /> Distance to Public Sewers /t Connection necessary : Yes_ No <br /> Does existing septic system comply with Ord . #549 : Yes— No_ <br /> Unknown If no, explain: <br /> Describe septic installation o be /,installed: <br /> N.4 <br /> 2. WATER SUPPLY <br /> Is water supplied by private well : Yes No_ Is well proper: <br /> Yeses No State deficiency: <br /> Does isting 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: K w.r <br /> 4 . FLY, MOSQUITO OR VNCTOR PLI NMIAS <br /> State possible vector potential & necessary control: <br /> n <br /> 5 . TOILET/BATH FACIU TF.S <br /> No . & location existing: IG Additional <br /> facilities needed <br /> 6 . PRFVTOOS GERRATION HISTORY <br /> 7 . GENERAL SANITATION <br /> State any problems not previously rioted : <br /> S . POPULATION DF.NSTTY <br /> Appx . No . People per eq . mi. <br />