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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes No-- <br /> Does <br /> o_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 + No Is well proper: <br /> Yes r 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 & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method : <br /> Potential problem: <br /> 4 . FLY MOSQUITO OR VrQTOR POfENTIAL <br /> State possible vector potential & necessary control : <br /> 5 . T ILET/BATH FACILITES <br /> No . & location existing: _ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION H QTORY <br /> 7 . GENERAL SANI'.L'jTll-W. <br /> State any problems nok previously noted : __--___ <br /> 8 . POPULATIO14DENSIT_Y <br /> Appx . No . People per Eq . mi . _ <br />