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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No <br /> Does existing septic system comply with Ord . 0549 : Yes No_ <br /> Unknown If no, explain : <br /> Desc ibe septic insta4ation, to 'be installed: <br /> 2 . MATER SUPPLY <br /> Is water supplied by private well : Yes No Is dell proper: <br /> Yes No State deficiency : <br /> Does xisting or porposed use make- this well public water: Yee <br /> No Sample of well water taken: Yes No ':i' Date taken <br /> Resul s Additional�r information or comments <br /> 3 . GARBAGE & R .F TSE <br /> Licensed scavenger pick-up: Yes Nos. Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4, gj,g� MOSQUITO OR V Z^.TCS p2MEZ1AL <br /> State possible vector potentiftl eA necessary control : <br /> 5 . TOTLET/BATH FACILITES <br /> No . & location exioting : Additional <br /> facilities needed _ <br /> 6 . PREVIOTTS OPERATTON HI STORY <br /> 7 . QENERAL SAIJIT '1„A ION <br /> State any problem: not Previously noted : o <br /> 9 . PAPULATION DEi1,,ITY <br /> A P p x. No . People per c . mi. �e! '�'� �ri�Cf =��✓�f�”- -7'-� <br />