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1 . 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 /> Licensed scavenger pi,--k-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem : <br /> 4 . ESL MOSQUITO OR V f.—T(7 E2r1.RT1ali <br /> State possible vector potentiftl 1.c necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: _ Additional <br /> facilities needed <br /> 6 . PREVTOU; OPERATION HTSTQRY- <br /> 7 . GENERAL SA L11AILO- <br /> State any problems not previously noted : - <br /> 8 . <br /> oted : _8 . PnIj,ATZOtd Dr iJ,.)ITY <br /> Appx. No . People per rq. mi. <br />