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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . 41549 : Yes_,,__ No_ <br /> Unknown If 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 /> Yee No State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water taken: Yes No ' Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLX MOSQUITO OR VE^TOS P.S)'rjLNTIdL <br /> State possible vector potentiftl PA necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & locution existing: ��`��� �'�`� Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SAPIIT TION f / <br /> State any problems not Previously noted : <br /> 8 . 2QPULATIOt4 DENSITv <br /> Apex. No . People per 6q. r,,i . �f'</�CICf :; `.,T•�'e�-��.f,� <br />