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Distance to Public Sewers Connection necessary: Yes No -­" <br /> Does exists ng septic system comply with Ord. #549 : Yee No— <br /> UnknownIf no, explain: <br /> Describe septic installation to 'be installed: <br /> 2. WATER SUPPLY <br /> Is water supplied, by private well: Yes ' ✓ No Is well proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make this well public water: Yes <br /> Nomple of well water taken: Yes No ::f Date taken <br /> Results Additional information or comments <br /> f <br /> 3 . QARBAGE & REFUSE <br /> Licenued scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem- <br /> 4. <br /> roblem:4. ELY, MQSQUITO OR VsQT02 _RQ.[ZH ILL <br /> State possible vector potential & necessary control: <br /> MoS u os o A/4A) <br /> 5 . TQILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6, PREVIOnS OHl(,;IORX <br /> 7 . UENERAL SNIION <br /> State any problems not previously noted: <br /> $ . POPULATION,DRN S TTY <br /> Appx. No. People per sq. mi. IeZ t +� -- <br />