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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 installation to 'be installed: <br /> 2 . DATER SUPPLY <br /> Is water supplied by private well : Yes clo Is well proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make this well public crater: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> S . GARBAGE.. & REFUSE <br /> Licensed scavenger pick-up: Yes `' No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: A-VIS' <br /> 4. FLY, MOSQUITO OR VRQTQR PQ'rj,NTTA <br /> State possible vector potentifcl & necessary control: A41) � <br /> 5 . TOILET/BATH FACIL TIES <br /> No. & location existing: fir ' Additional <br /> facilities needed <br /> $ . PRFVIORa OPERATION HISTORY <br /> 7 . GENERAL SAITTIATTON <br /> State any problems not previously noted:— <br /> S . <br /> oted:S . PQPULATT014 DFS, STTy <br /> Appx. No . People per sq. mi . �� <br />