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1 . SEWAGE <br /> Distance to Public Sewers _�/� Connection necessary: Yes N01— <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 /> Yes No,� State deficiency .- <br /> Does existing or purposed use make this well public water: Yes <br /> Nom Sample of well water taken: Yes No--_Z Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No ervice. Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . EIJ-, MOSQUITO OR Y '^UM)i'EENTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TQILET/BATH FACILITES <br /> No. & location existing: - A -- Additional <br /> facilities needed _ <br /> 6 . PREVIOUS ,OPERATION HISTORY <br /> 7 . GENERAL SANITATT N _ <br /> State any problems not previously noted: <br /> 3 . POPULATIQN DENSITY <br /> Appx. No . People per sq . <br />