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i . 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 SUPPLY <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 Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licenaed scavenger p:.ck-up: Yes No Service Area No. <br /> Other proposed disposed method: <br /> Potential problem:- <br /> 4. <br /> roblem:-4. ELX , MOSW TTO OR VEQTC?RP )'rrNTT `. <br /> State possible vector potential & necessary control: <br /> 5 . TOTLET/BATH FACTLITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . PRRVTOnS OPERATION HISIORY <br /> 7 . GENERAL. SAttTTATTON <br /> State any problems not previously noted : <br /> S . POPULATION DRH STTY <br /> AnAx. No . People per aa. mi . <br />