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1 . S E W A Ca E <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 /> Of <br /> Describe septic installation to be installed: <br /> 2 . MATER SUPPLY <br /> Is water supplied by private well : Yes No'2:'—L, 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 =f Date taken <br /> Results Additional' information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No-�;t-< Service Area No . <br /> Other proposed disposal method: <br /> Potential problem- ,h'o -eE <br /> 4 . FLY , MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PREVVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted : <br /> 3 . POPULATION DENSITY <br /> Appx . No . People per sq. mi . ������1%��,f �f./"iOer•�ri��� <br />