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1 . SAGE <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 /> 2 . {CATER SUPPLY <br /> Is water supplied by private well : Yes No-L Is well proper: <br /> Yes No State deficiency: <br /> C , <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 /> Licenaed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLY, MOSOUTTO OR VECTOR PQ'r2,NTTAL <br /> State possible vector, potentiftl A..& necessary control: <br /> 5 . TOILET/BATH FAC TES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PRRVIona OERRATION H1.,`.TD_ <br /> 7 . GENERAL 5MITI TA ION <br /> State any problems not previously noted: <br /> 3 . POPULATION DRHSTTY ' — <br /> Appx . No . People per sq . mi. IC/�. il"42d,eA <br />