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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 /> <11Desc b tic i sallation 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 Semple of well water taken: Yes No Date taken <br /> Ryersults Additional information or comments :Z _� i" c o';►..' <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem : <br /> 4. FljY-L MQSQUITQ OR VV Z^TQ Eff1B11AL <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing! � Additional <br /> facilities needed _ <br /> 6 . PRFVTQQ2 OPERATION HISTO n <br /> 7 . GENERAL SAPIITA'PION <br /> State any problem: not previously noted: — <br /> 8 . EQP1 ,ATIO14 DENSITY <br /> Appx. No. People per sq. mi. <br />