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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 wetter supplied by private well : Yes coo 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: Yea 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 . FAL MOSQUITQ QB VZ^.TQ ZC)M TIAL <br /> State possible vector potentiitl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : — Additional <br /> facilities needed _ <br /> 6 . PRE,V1002 OPERATI0111 HISTnrty <br /> 7 . GENERAL SAJITTa`rION <br /> State any problems not previously noted : <br /> 8 . F- > 1LATION hriIv <br /> Appx. No . People per sq . mi . <br />