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1 . GSWA , <br /> Distance to Public SewersP 4 Connection necessary : Yes Nom <br /> Does existing :septic system comply with Ord. #549 : Yes= No_ <br /> Unknown If no, explain: <br /> Describe septic i stallation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water suppl:_ed by private well : Yes ,,2L No_ Is well proper: <br /> Yes No State deficiency : _ ✓f <br /> Does existing or porposed use make this well public water: 'les <br /> No.Z, Sample of well water taken: Yes_ Nod Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSP, <br /> Licensed scavenger pick-up: Yes No_ Service Area No . <br /> Other proposed c.isposal method: <br /> Potential problem: <br /> 4 . ELY, MOSQUITO 0 --YR TOR PO' LNTTAL <br /> State possible vector potential & necessary control : �a �f <br /> 5 . TOL .T/BATH FACIT_,TTFS <br /> No. & location existing: Additional <br /> facilities needed cHf f.riti c� _o <br /> 6. PREVIOUS OPCRATION HISTORY <br /> 7 . GENERAL SANTTATT2U <br /> State any probleas not previously noted : <br /> 9 . P0PULATIOt7 DENST'ry <br /> APpx. No . People per eq. mi . �t�.Pi«L�uc°c ,rFfaf �� <br />