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1. SAG <br /> Distance to Public Sewers Connection necessary: Yes No <br /> Does existing septic system comply with Ord. #549 : Yes Nom <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: A aJ �r . <br /> 2. MATER SUPPLY <br /> Is Hater supplied. by private well : Yes No :L Is well proper: <br /> Yes too State deficiency: <br /> Does pxisting or porposed use make this well public dater: Yes <br /> No ✓ Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . <br /> Licensed scavenger pick-up: Yes � No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY- _MOQUITI-QR -Y_E TC?_ R POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5 . 'C_OLET/BATH FACILITES <br /> No. & location existing: Al)01 Additional <br /> facilities needed <br /> S. PRF.y,1naS QF.EF.ATInN HISTORY <br /> 7. GENERAT. SA?7TTATTON <br /> State any problems not previoualy noted: 1lizz <br /> 9 . POPULATION DFSNSTTY <br /> Appx. No. People per sq. mi. <br />