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1 . 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: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes Ho 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 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 . =L MOSQUITO OR <br /> State possible vector potentiftl 8.c necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No . & locution existing : _ Additional <br /> facilities needed _ <br /> 6 . PRFVIOQ3 OPERATION HISTORY <br /> 7 . GENERAL SAPU'r,A`]'Ic_)N <br /> State any problems not previousl- <br /> y noted: _ <br /> 8 . EOPULATIO14 TENSITY. <br /> Appx. No . People per r_.q . mi . <br />