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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: <br /> 2 . WATER SUPPLY <br /> Is water supplied .,bLy j:'Ygvate well : Yes iso 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 . FIiY-L MOSQUITO QB <br /> State possible vector poteft Ftl necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location, existing: _-- Additional <br /> facilities needed _ <br /> 6 . PREV_TOQS OPERATION HISTORY <br /> jI,,- fl-a"/ <br /> 7 . GENERAL SA1U `l()N <br /> State any problems not previoii l-y- noted:_ <br /> S . POPULATION hri T <br /> Appx. No . People per req. mi . <br />