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1 . SEWAGE <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 /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes _ iso_ 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_ Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSF <br /> Licensed scavenger pick-up: Yes_ No_ Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . Elie MOSQUITQ OR yE2, TO PCfL11T AL <br /> State possible vector potential & necessary control : <br /> 5 . TOTLFT/BATH FACILITES <br /> No . & location existing: _ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HIST <br /> 7 . GENERAL SANITAL,ION <br /> State any problems not prevlouel.y noted: <br /> 8 . pC)pUr,ATTON DENSITY <br /> Appx . No . People per sq . mi . <br />