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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 . 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 /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or commenls_gz�hC��� <br /> 3 . GARBAGE & R .FrrSF. <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . F[��-MOSQ ] TQi QR V aT_(_) ZCi'r T <br /> State possible vector potential & necessary control : <br /> 5 . Tn T/BATH FACT ,TTFS <br /> No . & location existing: Additional <br /> facilities needed <br /> 6 . PREVIOUS c; RR.ATI�t�TO£iY <br /> 7 . )N <br /> State any problems not previously noted :_ <br /> 3 . Fr,r�rrr.ATTnt� TY <br /> APpx . NO . Pe;ople per oq . r,,l <br />