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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes No_ <br /> Does existing septic system comply with Ord. 41549 : Yes 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 viell 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 . <br /> roblem,:4 . =L MOSQUITO OR V E^.TO ZCi'r1'N <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACI -TT '.S <br /> No . & location existing: — Additional <br /> facilities needed _ <br /> 6 . PRRVT_OQ2 OPERATION HISTORY- <br /> 7 . <br /> ISTORY7 . GENERAL SANITATION <br /> State any problem: not previously noted: - <br /> 8 . <br /> oted: _8 . POPULATION DEi4"31TAV <br /> Appx. No . People per sq. mi . <br />