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1 . S <br /> Distance to Public Sewers Connection necessary: Yes Nom <br /> Does existing septic system comply with Ord. #549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: 2 <br /> 2 . WATER SUPPLY <br /> Is water supplied by private wells 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— Nom Date taken <br /> Results Additional information or comments -�� <br /> 3 . GARBAGE & REFUSE <br /> Licenced scavenger pick-up: Yes. No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, M4SQUITQ OR MOTOR EQ'rP,,NTTAL <br /> State possible vector potentiftl 8.c necessary control:. <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVTOnS OPRRATIQM H STORX <br /> 160,ele 'd��.Cf <br /> 7 . GENERAL SANT. TTON <br /> State any problems not previously noted: <br /> 3 . PCIPt)LATION P YSTTV <br /> Appx. No. People per sq. mi .���i«�„��/��- �'F✓-�F� �v <br />