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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 /> oe <br /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : YesNo Is W-11 proper: <br /> Yes No State deficiency : '*,�E � fi4 <br /> /3.�� [/r4� .0��.�+� � __ �' '" a" 7 tx •�J`l.i/!.�c` e. �cr' ,.i: ,s'r s e. <br /> Does existing or porr. osed use make this wel� public water : Yes <br /> No—_„Z_ Sample of well water taken : Yes Nom Date taken <br /> Results Additional information or comment's <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger P.Lck-up: Yeses No Service Area No . <br /> Other proposed disposal method : <br /> Potential problem:___ <br /> 4 . FLYS MOSQUITO OR YECT R F-C)ML`LLI LL <br /> State possible vector potential & necessary control - <br /> 5 . <br /> ontrol :5 . TQ T LR /BATH FAC I L I'I'ES <br /> No. & location existing: � _ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANI',LA7,I <br /> State any problems not previously noted- 0_41 if <br /> 8 . POPULATIQN DELkla y <br /> Appx . No. People per <br />