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. . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No— <br /> Does existing septic system comply with Ord. #549 : Yes 'f No� <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> OAJ <br /> 2. WATER-ZURPLY <br /> Is wa r supplied. by private well: Yes No Is well proper: <br /> Yes No State deficiency <br /> Doessting or porposed use make this well public water: Yes <br /> No Sample of Well Water taken: Yes Nom Date 'taken <br /> — <br /> Results Additional information or comments <br /> 3 . QAHHAGE & REFUSE ' t . <br /> Licensed scavenger pick-up: Yes �o Service Area'-No. <br /> Other proposed disposal method: 0102 <br /> Potential problem' -- - <br /> 4. ECTOR 20TRNTIAL <br /> State possible vector potential & necessary control: <br /> 5 . TOTLETZDATH FACILITES <br /> No. & location exis ting: loll. Additional <br /> facilities needed <br /> 6. EREYSORS OPERATIOM HISTORY <br /> 4- <br /> 7 . UENERAL SANIMAITQH <br /> State any problems not previously noted: <br /> 8 . pCfPC1LATION DESH5 v <br /> Apex. No. People per sq. mi . <br />