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SKWAQE <br /> Distance to Public Sewers -VA' 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 SUPPLY <br /> Is water supplied. by private well : Yes No Is well proper: <br /> ?Yes Na State deficiency: <br /> Does "fisting or porposed use make this well public Water: Yes <br /> Noy Sample of well water taken: Yes No_�Date taken <br /> Results Additional information or comments <br /> 3 . QARB,GE & REFS <br /> Licensed scavenger pick-up: Yes No ✓ Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR VECTOR 22CENTI_AL <br /> State possibly: vector potential & necessary control: <br /> 5. TQILET/HATH FACILITES <br /> No. & location existing: M'781"c H'M6' Additional <br /> facilities needed <br /> 6. PRRyIaga UERATIntd HISTnay <br /> 7. MERAL SANITATTON <br /> State any problems not Previously noted: <br /> S . POPULATIdN nRHSTTY <br /> AppA. No . People per .sq. mi.- <br /> R��'�-- <br />