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1 . SEWAGE <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 <br /> Is water supplied by private well : Yes Pio Is well proper: <br /> Yee No State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No SaNple 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. MOSQUITQ OR V.j'�TOR p )EENTT L <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/PATH FACILITES <br /> No. & location exi.oting: _ _ Additional <br /> facilities needed_. <br /> 6 . EgEVjona O pyRATToU HISTOFY <br /> 7 . GENERAL SANT. TION <br /> State any problems not previously noted: <br /> 3 . POPULATION DENSTTY <br /> APpx. No . People per aq. mi . — -- - <br />