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1 . BEL 4i' 5 T <br /> Connection necessary: Yes No� i <br /> Distance to Public Sewers <br /> Does existing septic system comply with Ord. #549 : Yes No— <br /> Unknown If no, explain: , _ <br /> Describe septic installation to 'be installed: <br /> 2. WATER SQPPLY <br /> Is water supplied, by private well : Yes L No Is well prover: <br /> yew,, No State deficiency : <br /> Does existing or porposed use made t1lis well public Nater: Yes <br /> i <br /> NoSample of well water taken: Yes no Date taken <br /> i Results Additional information or comments <br /> 3 . <br /> Licensed scavenger pick-up: Yes No Service Area No,. <br /> Other proposed ,disposal method.- <br /> Potential problem.- <br /> 4. ELY, MUQUIM 03-YEOTO <br /> State possible vector potential necessary control: <br /> 5 , TQTLFT/BATH EAOTLTTES Additional <br /> No. & location existing: <br /> facilities needed <br /> S. QEj C. mTOU. . S ORy- <br /> ` (1j fLX <br /> 7 . UI NF,RAL SAP TT `1�A 'ION <br /> State any pro'blemz not Previously noted: <br /> ---�v ry <br /> 8 . flC}T3UL6TTOt4 DEMST1a <br /> Appx. No . People per ..eq. <br /> h <br />