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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 . SEATER SUPPLY <br /> Is weer 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: Yes <br /> No z Sample of well water taken: Yes No Date taken <br /> Results Additional information or comIfients <br /> 3 . GARBAGE & REFUSE <br /> . Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . =,,- MOSQUITO OR Y I:- ? 'FAME TIAL / <br /> State possible vector potenti&I & necessary control : �6 <br /> 5 . TQILET/BATH FACILI7a <br /> No. & location existing: 41� Additional <br /> facilities needed_ <br /> 6 . PREVIOUS QPERATION HIS ,ORY <br /> 7 . GENERAL SANUf�J,'IOU <br /> State any problems not previously noted- <br /> S . <br /> oted:S . POPULATIO14 =1=1 <br /> Appx. No . People per sq. mi. <br />