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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes Nor <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 <br /> Is water suppliedby private well : Yes No 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 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. FLI, MQSQUITQ OR V (-) ZC)E2NTIAL <br /> State possible vector potentiftl & necessary control : <br /> 5 . TnT_LET/BATH FACILITES <br /> No. ec location existing: Additional <br /> facilities needed _ <br /> 6 . PREVTOUS OPERATION HIST <br /> 7 . CEN +ORAL SANIT 'tA_ION <br /> State any problems not previously noted : _ <br /> 8 . POPULATION DENSITY <br /> Appx. No . People per Bq. mi . <br />