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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes Nod✓ <br /> Does existing septic system comply with Ord. 11549 : Yes NOZ <br /> Unknown If no, explain: <br /> .- <br /> u'7 54a <br /> Describe septic installation to 'be installed: 4?1Cf /r <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes LHo Is well proper: <br /> Yes � No State deficiency: <br /> Does existing or porposed use make this well public water: Yes <br /> No U Sample of well water taken: Yea No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & R .FUS . <br /> Licensed scavenger pick-up: Yeses No Service Area No. <br /> Other proposed disposal method: A <br /> Potential problem: <br /> 4 . F,jLY-L_MOSQUITQ OR V ' ICI PCT I IAL <br /> State possible vector potentiztl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: _ �' Additional <br /> facilities needed _ <br /> 6 . PREVTOTTS OPERATjO • O t <br /> Lid <br /> 7 . URNERAL SAIITTa ION <br /> State any problems not previously noted:_ <br /> 8 . FSOaILATION DENSITY r <br /> Appx. No. People per Bq. mi . <br />