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1. SRbIAGE <br /> Distance to Public Sewers Connection necessary: Yes No,'&, <br /> Does existing septic system comply with Ord. #545 : Yes/ No <br /> Unknown - If no, explain: <br /> Describ s pti installation to 'be installed: <br /> F <br /> 2. WAIER S[]PPLY <br /> Is Water supplied. by private, we 1: Yes o Ie wellproper: <br /> Yes No,,4— State def;cieney.. AFI C4 <br /> Does existing or porposed use make this well public crater: Yes <br /> No Sample of well water taken: Yes NOL4 Date taken <br /> Results Additional information or comments <br /> k <br /> 3 . CCARPACE &_RFEUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. ELY• MOSAUITQ 0_ R VECTOR POTENTIAL <br /> State possible vector potential necessary control: <br /> 5 . TOILET/BATH FACT IRS <br /> No. & location existing: _ Additional <br /> facilities needed - • -• <br /> S. QUHISIORX <br /> 7 . QENERAL SAITTIATI-ON <br /> State any problems not previomal.y noted: <br /> 8 . POMILATION 12EH5TTY <br /> Appx. No. People per eq. mi.�i_z'6616 �•C •�1E� i .0 <br /> r <br />