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i . 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: )i A'iP <br /> 2 . WATER SUPPLY IJ <br /> Is water 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 /> Na Sample 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 , tiOS QUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TOI_ .T/BATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . ENE AT. SANITATION <br /> State any problems not previously rioted : <br /> S . POPULATION DENSITY <br /> Appx. No. People per sq . mi . <br />