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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 No Is well proper: <br /> Yee 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 /> S . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem- <br /> 4 . <br /> roblem:4 . ELY, MOSQUITO OR V 1^Tn �i'j' ,NTIAL <br /> State possible vector potentiftl Rz necessary control: <br /> 5 . TOTLET/BATH FAC7I111E <br /> No. & location existing: - Additional <br /> facilities needed - <br /> 6 . PREVInnS opERATToN HTsTnRY <br /> 7 . GENERAL SANT jAjIQN <br /> State any problem.- not previously noted: <br /> 8 . POPULATIO14 DENSTTY <br /> Appx. No. People per eq. mi . - — <br />