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1 . SFSIAGF <br /> Distance to Public Sewers 11 Connection necessary : Yes Nom- <br /> Does existing septic system comply with Ord. #549 : Yeses. No_ <br /> Unknown If no, explain: <br /> Describe septic nsallation to 'be instt <br /> f� <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is viell proper: <br /> Yes . No State deficiency : <br /> Does existing or porposed use make this well p blic water : Yes <br /> No-A- <br /> Sample of well water taken: Yes NOM 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 . ELLY-L MOSQUITO OR <br /> State- possible vector potentiFtl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: Additional <br /> facilities needed — _ <br /> 6 . PREVIOPS OPERATION HISTORY <br /> RY <br /> 7 . GENERAL SAIJIT '1-A ION <br /> State any problems not previously noted : _ <br /> 8 . POPULATIO14 DENSITY <br /> Appx . No . People per 13q. mi . <br />