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E <br /> 1• SEWAGE <br /> Distance to Public-.Sewers Connection necessary: Yes No� <br /> Does existing septic system comply with Ord. 0545 : 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 : Yes No is well proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make tilis well public water: Yes <br /> No Sample of well water taken: Yes Pio 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. ELY,, MMUM. OR__Y�'-"To igP T. T IbL <br /> State possible vector potentiftil necessary control: <br /> 5 . MILET/BATH -EAQUITES <br /> No . ek location existing: Additional <br /> facilities needed <br /> 6. ERE VIOUS OPERATION HISTORY <br /> f <br /> 7 . GENERAL 56 11 A'i'R N <br /> State any problems not previously noted <br /> f <br /> 9 . FLE)PULAT1014 DEM ST V <br /> Appx. No. People per sq. .mi. <br />