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1 . .9EWAGE <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 /> Z . 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 pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . EILY , M 0 S 0 U I T 0 OR VEMT CM–M) KIAL. <br /> State possible vector potentiftl & necessary control : <br /> 5 . TQTLET/BATH FACILITES <br /> No . & location existing: Additional <br /> facilities needed <br /> 6 . PRF,VIOUL OPERATION HISTORY <br /> 7 . GENERAL SAtITT '1_A 'ION <br /> State any problems not previously noted : - <br /> 8 . <br /> oted : _g . POPULATI014 DENST11 <br /> ADnx. No . People per rq . mi . <br />