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M '/ � <br /> Distance to Public Sewers � Connection necessary: Yes No_.._ <br /> Does existing septic system comply with Ord. #549 : Yes No— <br /> Unknown If no, explain! <br /> Describe septic Inst llation to be installed: d ✓' �' T� °� <br /> Q f <br /> 2 . WATER SUPPLY <br /> Is wate .- supplied by private well: Yes 4--_No Is well proper: <br /> Yes No State deficiency <br /> Does existing or porposed use make thin well public water: Yes <br /> Noof well water taken: Yes NoAet—_"Date taken <br /> Results Additional information or comments <br /> . Licensed scavenger pack-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. �.P.CC)LENTIAL <br /> Stag possible vector potential. & necessary control ! <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing : _ Additional <br /> facilities needed <br /> 6 . PREYIOUS CPERATIQN HISMU <br /> ? . GENERAL SANITATZQ& <br /> oted8State any problems not previously noted: - <br /> 8 . <br /> . EQPQ ,A=1L.UE.t _1 <br /> Appx. No . People per sq. mi . <br /> 7 � � r� r.t.,�.� /►��...,� � � � S � off' <br /> �� / c <br />