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1 . AGE <br /> Distance to Public Sewers Connection necessary: Yes No— <br /> Does existing septic system comply with Ord. #548 : Yea No_ <br /> Unknown if no, explain: <br /> Describe septic installation to -be installed: <br /> 2. WATER SUPPLY <br /> private well: Yes iso is well proper: <br /> Is wat supplied by p <br /> Yeso State deficiency: <br /> Does existing or porposed use make this well pubLkc water: Yes— <br /> No__ I'-Sample <br /> esNoSample of well water taken: Yes No Date taken <br /> Resu to Additional information or comments <br /> 3 . GABRAGE & REFUSE <br /> Licensed scavenger pick-up: Yes NO Service Area No.� <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY. MQSQUIIQ OR ," r PUCENTIAL. <br /> State possible vector potential & necessary control: <br /> 5 . n r r <br /> No. & location existing: --.-- Additional <br /> facilities needed <br /> r- <br /> 6 . EREVIMS OTERATIOU HISTORI <br /> LZ <br /> i 7 . GENERAL SAUTjA'tTQjj <br /> State any problems not previously noted: <br /> 8 . BQPULAIIQ14 j2EHSTTV. <br /> Appx. No. People per .aq. mi. <br /> r <br />