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1 . SFWAGF� <br /> Distance to Public Sewers Connection necessary: Yes Ne <br /> Does existing septic system comply with Ord . 0549 : Yes Y No <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is Rater supplied by private well : Yes i�o \`f 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 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. MOSQUITQ OR VEQTOR PQ'fjjjLT_ <br /> State possible vector potentiFtl & necessary control : <br /> 5 . TOILET/BATH FACUT 'FS <br /> No . & location existing: /" Additional <br /> facilities needed _ <br /> 6 . PREV1002 OPERATION H3 OF+'Y <br /> I � <br /> 7 . GENERAL EANIT '1.A ' -C-M � <br /> State any problems not previously noted:_ <br /> 8 . POPULATION DE NSTTY <br /> Appx. No . People per sq . mi ._ <br />