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1 . SEWAGE /(�� � <br /> Distance to Public Sewers Connection necessary : Yes Nod` <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 /> Yee No State deficiency : <br /> Does�xist.ing 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 . GARBAGj—&-jBZM <br /> Licenced scavenger pick-up: YesV No Service Area No. <br /> Other proposed disposal metho : <br /> Potential problem:_ dwl <br /> 4 . ELY, MOSo= ORyr,Q TnR P0'rI;NTIAL <br /> State possible vector <br /> ecor potential necessary control: <br /> 5 . TOILET/BATH FACI TIM, <br /> No . & locution existing: Additional <br /> facilities needed. <br /> 6. PREVIOftS C; tRA Ire% �jTS 0RY <br /> 7 . GENERAL SANTIAT,101i V Lliy'� <br /> State any problems not previouOly noted : <br /> $ . POEULATIQU DIENSI " �{ <br /> APAx. No . Peo"r,,ie Tnc-tr sac mi . �" <br />