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1. SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord. 11549 : 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 /> 8 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes ', No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY. MOSQUITO OR VrZTOR pC)fENTIAL <br /> State possible vector potentictl & necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: ( ' t' Additional <br /> facilities needed <br /> 6. PRRVTO02 O aRAT ON HISTORY <br /> 7 . GENERAL SANTIATTON <br /> State any problems not previously noted: <br /> 8 . POPULATION DF. STTY <br /> Appx. No . People per eq. mi . <br />