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1. SVGS <br /> Distance to Public Sewers Connection necessary: Yes_ No_ <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 % L) d G <br /> Is water supplied by private well: Yes _ No_ Is well proper: <br /> Yes_ No_ State deficiency: <br /> Does existing or porpoeed 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: <br /> 4. FL.Y, MOSAUTTO OR VRCTOR POTENTTAL <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVIOUS OPERATION HISTORY <br /> L/-a-z:c" L IV c-4 <br /> 7. GENERAL SANITATION <br /> State any problems not previously noted: <br /> 9 . POPULATION DENSITY <br /> Appx. No. People per eq. mi. <br />