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1 . SEWAGE <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 installation to be installed: <br /> 2 + WATER z <br /> Is water supplied by private well: Yes No Is well proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make this well public water: Yes <br /> No Samples of well water taken: Yes No Date taken <br /> 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 . <br /> State~ possible vector potential & necessary control : <br /> 5 . C <br /> No.. & location existing : _ Additional <br /> facilities needed <br /> 6 . EREVIOUS QEERATIQN <br /> 7 . GENERAL SAILITfT-LM <br /> ita.te any problems not previously noted: <br /> 8 . POPUL 6TIQN DENSITY <br /> ' Appx. No. People per sq. mi. <br /> f <br />