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1. <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord. 0549 : Yea -/ No_ <br /> Unknown If no, explain: <br /> Describe geptic installation to 'be installed: <br /> Y I <br /> 2. WATER SUPPr.X <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 /> Nom_ Sample of well water taken: Yes No Date taken <br /> Results - Additional information or comments <br /> 3 , GARB&QE <br /> Licensed scavenger pick-up: Yea -' No Service Area No. <br /> Other Proposed disposal method: <br /> Potential problem: <br /> 4. FLY. SAUIT _QR VEQ!EnR Pn'rl:,NTTAi. <br /> State possible vector potential necessary control: <br /> 5 . TOTLETZBATH FACTLITTES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVInnS r XR TIQU HISTORY <br /> 7. GENERAL SANIT&TION ) <br /> State any problems not previously noted: <br /> S . RQUILATION DM;jTTV <br /> APPX, No. People per sq. mi. ' <br />