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I . S E dAGF <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 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: Yeg 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 . FLY. MOSQUITO OR VEQT(-)R PO'rjyNTTAL <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACT ,ITES <br /> No . & location existing: Additional <br /> facilities needed <br /> 6 . PRRVIOns OPRRATInN HT sTnRY <br /> 7 . GENERAL SANT^' TTON <br /> State any problems not previouzl7 noted : <br /> 3 . PO PULATIntN DFHSTTv, <br /> APPx. No . People per 3.i . mi . <br />