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1 . SRWAGrj <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord. #545 : 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 /> T . J_ Q'� ._ rte/ a,� �u�Y1 . ' .5 ` <br /> Does existing or porposed use matte this, well public water: Yes <br /> No Sample of well water taken: Yea No Date taken <br /> Results Additional information or comments <br /> 3 . <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential probiei: <br /> 4. FLY, OR VEQTQR PQ'fMjL &L <br /> State possible vector potential necessary control: <br /> 5. T4 /BATHIACTLITES <br /> No. & location .existing: Additional <br /> facilities needed _ <br /> 6 . PkFVIOT]fi--CPER.ATION HISTORY <br /> 7 . QRNEAAL SAN I TAI I QN i <br /> State any problems not previous l y noted: <br /> S . ROULATION DEMUivl <br /> .. <br /> Appx. No. People pereq.• mi. <br /> ,49/� <br />