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1 ' Dist ' <br /> Distance to Public Sewers lZe Connection necessary: Yes No <br /> Does existing septic system comply With Ord. 0549 : Yea=, No_ <br /> Unknown If no, explain: <br /> Descr}be septic installation to 'be installed: <br /> .fdiJ ,f O�/iLf4 <br /> 2. WAT .R SUPPLY <br /> Is Water supplied by private wel Y No Is "? l proper: . <br /> Yes No_ State deficiency: <br /> 4/9�•f /' �1®cllE s���� <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water taken: Yes_ NO-4 Date taken <br /> Resul Additional information or comments <br /> 3 , GARBAGE. & RRFUSK <br /> Licensed scavenger pick-up: Yes No_ Service Area No. <br /> Other proposed disposal method! <br /> Potential problem: <br /> 4. F(.Y. MOSQUITO OR VMCTOR DOTE TTA . <br /> State possible vector potential & necessary control: �' '�'f <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PRRVTOUS OPERATION HISTORY <br /> 7 . GENERAL SAN TATT N <br /> State any problems not previously noted: <br /> 8 . PoPTIT,ATT014 DBNSTTY <br /> Appx. No. People per sq. mi. �l�f�c✓� -QF �cSt�4F�! �� ` <br />