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1 . SEWAGE <br /> Distance to Public Sewers i, Connection necessary: Yes No— <br /> Does existing septic system comply with Ord . 0549 : 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 dell proper: <br /> Yes No State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No ^' Sample of well water tarsen: 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 . FLYS MOSQUITQ OR <br /> State possible vector potentiftl Fz necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: e� Additional <br /> facilities needed _ <br /> 6 . PRFVIOnE OPERATION HISTORY <br /> r <br /> 4/ OaFP <br /> . F-• a O <br /> 7 . GENERAL, SANIT_PATION <br /> State any problems not previously noted: <br /> 8 . POPULATION DENSITY <br /> Appx. No . People per 6q. mi . �����/ ��-��.1/✓�'��r�.� <br />