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1 . SSE <br /> Distance to Public Sewers Connection necessary : Yes No <br /> Does existing septic system comply with Ord. #549 : Yes T No_ <br /> Unknown If no, explain : <br /> Describe septic installation to be installed: ti-'�i4� <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes .jL No_ Is well proper: <br /> Yeses No_ State deficiency : <br /> Does existing or porposed use make this well public water: Y <br /> Nom_ Sample of well water taken: Yeses' No_ Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REPOSE <br /> Licensed scavenger pick-up: Yes ' No_ Service Area No. <br /> Other proposed disposal method! <br /> Potential problem: <br /> 4 . FLY , MOSQUITO OR VECTOR POTENTTA , <br /> State possible vector potential & necessary control : <br /> 5 . TQILET/BATH FACTT,TTF.S <br /> No . & location existing: / Additional <br /> facilities needed _ <br /> 6. PREVIOOS OPERATION HISTORY <br /> 14 L-A GM,.j h <br /> 7 . GENERAL SANTTATTON <br /> State any problems not previously noted: <br /> 9 . POPULATION DENSITY <br /> Appx . No . People per aq . mi . <br />