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f.. S HWAas /V <br /> Distance to Public Sewers Connection necessary: Yes No <br /> Does existing septic system comply with Ord. #549 : Yes No— <br /> Unknown- <br /> o—Unknown - If no, explain: <br /> Describe septic installation to 'be installed: ._.. . IZr vx 4„ <br /> 2 . WATER SUPPLY <br /> Is Water supplied. by private well : Yes No Is well proper: <br /> Yes No State deficiency: <br /> Does pxisting or porposed use make this well public Water: Yes <br /> NoSample of well water taken: Yee No Date taken <br /> Results— Additional information or comments <br /> 3 . <br /> Licensed scavenger pick-up: Yes4— No Service Area No. <br /> r Other proposed disposal method: <br /> Potential problem: <br /> 4. WILY, MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential necessary control: <br /> i <br /> 5 . TOLETZDATH FAfJ.L=- <br /> No. & location existing: L m Additional <br /> facilities needed <br /> 6 . PREY10nS OPER.AIIOU .HTSIORY <br /> 7. QENERAL SANITAlIQU <br /> State any problems not Previously noted: <br /> S . O ➢ ''T wy <br /> Appx. No. People per .sq. mi. dt/ � <br />