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1 . SAGE <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 No 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 . L MOSQU_ TQ QB U2.10ECi'M TIAL <br /> State possible vector potentiitl & necessary control: <br /> 5 . TOILET/BATH FACTL�ITES <br /> No. & location existing : Additional <br /> facilities needed _ <br /> 6 . PREVIOQ2 OPERATION HISTORY <br /> 7 . GENERAL 2A2ITT '1,A 'ION <br /> State any problems not previously noted: — <br /> 8 . EOPULATIO14 DENSITY, <br /> Appx. No . People per 6q . mi . <br />