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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No— <br /> Does <br /> o/Does existing septic system comply with Ord . #549 : Yeses 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 /> Resu �s 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_MOSQUjTO OR V QTO PC)fLRT_A.T" <br /> State possible vector patentiftl & necessary control : <br /> t <br /> 5 . TOILET/BATH FACILITES fr, <br /> No. & location existing: '` i -i Additional <br /> facilities needed _ <br /> 6 . PRFVTOTI,S_ OPERATION HISTORY- <br /> 7 . <br /> ISTO r7 . GENERAL SAIIIIAIJ-0- <br /> State any problem: not previously notel: _ <br /> 8 . POPULATION Dr'1STTY <br /> Appx. No . People per 6q . mi . <br />