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SFS <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 /> Describe septic installation to 'be installed: <br /> 2 . MATER SUPPLY <br /> Is water supplied by private well : Yes1�G No Is well proper: <br /> Yes4�,-�o 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 /> ZX <br /> *'1 <br /> )'0'4 <br /> e& <br /> y *74 <br /> 3 . GAR AB GLUT &tREFU E•� � op <br /> f ',j " �� i.* ' �� /a►,,.� <br /> Licenced scavenger pick-up: Yes No St rea o. T r <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. F11L. MOSQUITO QR VEQI-PS) NTIAL <br /> State possible vector potentiftl FA necessary control : <br /> 5 . TOILET/BATH FACILI ' S <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PRFVTQfJ,_ QPI RATION HISTO f <br /> 7 . GENERAL SANITATION <br /> State any problem: not Previously noted : _ <br /> 3 . RnPULATION DENST v <br /> Appx. No . People per cq . mi. � <br />