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t i <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. WATMR SaPPLY <br /> Is water supplied by private well: Yes ala Is fre11 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 & RREUSH <br /> Licensed seavenaer pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 o i- <br /> State possible vector potential & necessary control: <br /> 5. 101LFTMTH CACTLITEa <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVTOnS OPER . 0 <br /> 7 . GENERAL SANTMAT7nN <br /> State any problems not Previously noted: <br /> C <br /> a . t7 ''T v <br /> E APpx. No. People per .sq. mi. <br />, <br /> t <br />