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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes Nov <br /> Does existing septic, system' comply with Ord . #549 : Yes No <br /> Unknown If no, explain: <br /> Describe septic ins-'allation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No V, Is well proper: <br /> Yes No State cieficiency : <br /> Does /e or porposed use make this well pubic water. Yes <br /> No Sample of well water taken: Yes No ✓✓ Date taken <br /> Results Addl/i-ti.onal information or comments <br /> `P135, �C K-Cyyt" CT,_`, a S w0 <br /> 3 . <br /> Lice ed scavenger pick-up: Yes No Service Ar" No . <br /> Other oposed disposal method: <br /> Potentia roblem: ___ —� <br /> 4 . FLY, MO. QTJTT OR <br /> 1Pi NTIAL <br /> State possible vector potential s necessaty control : <br /> 5 . TQILET/BATH FACIL_0'EQ-_ <br /> No . & location existing: _ Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPER&TION HI TA= <br /> 7 . GENERAL <br /> State any robl in 1� t previously noted: <br /> 8 . PQJJQ ,ATIQN DEP l= <br /> Apex . No . People per sq. mi . - <br />