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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes_ No_ <br /> Does existing septic system comply with Ord . 0549 : 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 /> Yes_ No_ State deficiency :_ <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water tarsen: 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: <br /> 4. ZLY_� MOSQUITO OR V Z^.TO pSf.LiT_1A;i <br /> State- possible vector potential & necessary control : <br /> 5 . TOILET/BATA FACILITES <br /> No . & location existing: _ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HIST Y <br /> 7 . SENERAL UM ATION <br /> State any problems not previously noted : <br /> a . POP[I LATION ENdpTjv <br /> Appx. No . People per 6q . mi . <br />