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1 . SEWAGE <br /> Distance to Public Sewers ^� Connection necessary: Yes NoX <br /> Does existing septic system comply with Ord. 41549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installatiop to 'be installed: <br /> 'an�2 r�tTr,i <br /> 2 . MATER SUPPLY <br /> Is w r supplied by private well : Yes No Is well proper: <br /> Yes eNo State deficiency : <br /> Doe existing or porposed use make this well public water: Yes <br /> No-4— Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REF <br /> Licensed scaven er pick-up: Yes No Service Area No . <br /> Other proposed d posal method: <br /> Potential problem: <br /> 4. FLY , MOSQUITO OR V EC)EENTI <br /> State possible vector`potentiftl & necese, <br /> ry control : <br /> 5 . TOTT.ET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HI`TORY <br /> 7 . GENERAL SANTIA ION <br /> State any problem: /nprevlouely noted : _ <br /> 8 . F P LATION DENSITY <br /> Appx. No . People per sq. mi . <br />