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1. SXWAPaF� <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 installationa installed: <br /> 2. WATER SUPPLY <br /> Is water supplied. b-y private well : No_ Is well proper: <br /> Yes–LZHo State deficiency: <br /> Does existing or porposed use make this well pubs.-ic Water: Yes <br /> No__"--Sample of Well water taken: - Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBFLt`E A REyEUSE <br /> Licensed scavenger pick-up: Yes Na Service Area No.� <br /> Other proposed disposal method: <br /> Potential problem- <br /> 4. <br /> roblem-4• FLY- MQS!@! lIQ 0R V Q 02 ECI'£ENTIAL <br /> State possible vector potentia.1,46 necessary control: <br /> 6 <br /> 5 . T–ILETLEATH EACUTTES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVIOU MrggTTntt HISTORY <br /> i <br /> s 7. QFNERAL SANITATION <br /> State any problems not previously noted: <br /> 3 . POP[iLATiOH PFNSITY <br /> Appx. NO. People per sq. mi. <br />