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1 . SEWAGE <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 x1stal lation t 'be installed- <br /> 4111z' <br /> nstal led:— <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well - , Yeses No Is well proper: <br /> Yes No State defi'gienc 7 . ay l,C <br /> �/ ��I// i..r�ofE�1.C�%Jf�r Fo /�i,.� is'� 9.t��`��✓ /�P o��'6 i a .f),��G <br /> Does existing or porposed use make this well public water : Yes <br /> No�_ Sample of well water taken: Yes Noz' Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE f, � <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLY. MOSQUITO OR yQ'1L) P_C)'M1U1AL <br /> State possibly vector potential & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : - _ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HJ T 2 <br /> 7 . GENERAL SANLEAZLM <br /> State any problems not previously noted.- <br /> 3 . <br /> oted:8 . POPULATION DEHS= <br /> A p p x . No . People per sq . mi <br />