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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes No— <br /> Does existing septic system comply with Ord . 0549 : Yea No_ <br /> Unknown If no, explain: <br /> Describe septic insta:_lation to be installed: <br /> Z . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make this well public water: Yea <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 V Qa–Z2f2NTIAL <br /> State possible vector potentiftl & necessary control : <br /> 5 . TOTLET/BATH FACILITES <br /> Na & location existing: Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HIST _ RY <br /> 7 . GENERAL SAIJITATION <br /> State any problem: not previously noted- - <br /> 8 . <br /> oted: _3 . POPULATION DENISTTY <br /> Appx. No . People per sq . mi . <br />