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wk� <br /> 1 . SEWAGE � � <br /> Distance to Public Sewers _ Connection necessary: Yes No <br /> �,/ <br /> Does existing' septic system comply with Ord . #545 : Yes No_ <br /> Unknown If no, explain: <br /> _ <br /> A,) c S-r t IS' <br /> Describe septic installation to be installed: <br /> irn_p <br /> 2 . WATER SUPPLY <br /> Is water s plied b`, private well : Yes Nass well proper: <br /> Yes_ No V State deficiency' <br /> Doesxisting or porposed use make this well pub,-ic water: Yes <br /> No Sample of well water taken: Yes Na V Date taken <br /> Results Additional/ information or comments <br /> 3 . <br /> . Lie sed scavenger pick-up: Yes No ServicZea . <br /> Othe proposed disposal method: <br /> Poterxt 1 problem: <br /> 4. FLYTIAL <br /> State possib vector potential & neces ary control: <br /> 5 . TOILET/BATH FAGII�LT <br /> No. & location exiuting: z _ Additional <br /> facilities needed _ <br /> 6 . <br /> 7 . GENERAL SANT,r 'TON <br /> State aril► P blemss not previously noted: <br /> 8 . POP IT. ON DENSTT <br /> App No. People per sq. <br />