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r� <br /> 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 by private well : lies Na Is well proper: <br /> Yes too 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 . FILA ) PQ' M IAL <br /> State possible ve Rr potential & nem scary control : <br /> 5 . TOILET/BATHFAO'II,LTYM ` <br /> No. & location existing : Additions] <br /> facilities needed <br /> 6 . P_REV_IOUS_ OPERATIQN _ =1 <br /> T. GENE L SAPdI'. A 1�MH <br /> State any problems not previously n ted: <br /> 3 . pQI'UL,ATI ON_ .12ENSI TY <br /> Appx. No . People per eq. mi. __ _ <br />