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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No . <br /> Does exg septic system comply with Ord . 0549 : Yes No <br /> Unknowni I f no explain: <br /> Des ribs septic insula ian to..'be nstalled: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private we'1 : es No I pz :1 proper•,/ <br /> Yes No State deficiency: <br /> ���, �� ' �9�f/1� <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water taken: Yes NoDate. take <br /> Results Additional information or omments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes N Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . =� MOSQUITO OR VECTOR PS►_TEi T rS <br /> State possible vector potentiftl necessary control : - <br /> 5 . TOILET/BATH FACIj�TTES <br /> Na. Fc location existing: Additional <br /> facilities needed <br /> 6 . PRFVTons npEgATIOi; HIST <br /> 7 . GENERAL RAL SAjJITA'1'ION <br /> State any problems not previously noted: .4' <br /> 8 . POP[JLATI014 hr 11:->?TY , <br /> Appx. No . People per sq. mi . ... <br />