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S <br /> 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: :,/1 <br /> 2 . MATER 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 we'll public water: Yes <br /> No Sample of well water takers: Yes NoZ_ 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 . ELL.,- MOSQUITO QR Y Q ) 'LiTBNiJAL <br /> State possible vector potential & necessary control : <br /> 5 . TQ LI ET/BATH FACILITY <br /> No. & location existin Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERATE SANITA'I'SM <br /> Sta.te any problems not previously noted: <br /> 8 . FOPULATIOiL. i=11 <br /> Appx. No. People per sq. mi ._ <br />