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1 ' ist <br /> Distaann ce to Public Sealers m <br /> C Connection necessary : Yes_ No <br /> D <br /> Does existing septic system comply With Ord . tt549 : Yes_ No_ <br /> Unknown IE no, explain : <br /> Describe septic installation to be installed: !/lralG <br /> 2 . WATER SUPPLY <br /> Is Water supplied by private well : Yes _ No_ Is well proper: <br /> Yes_ No_ State deficiency: <br /> Doeexisting or porp:>sed use make this well public water: Yes <br /> No 4V Sample of well water taken: Yes_ No_ Date taken <br /> Results Additi-Dnal information or comments <br /> 3 . CARRAGE & RRFUSR <br /> Licensed scavenger pick-up: Yes r No_ Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: 1) iV <br /> 4 . FLY, MOSQUITO OR VC t)R POTENTIAL <br /> State possible vector. potential & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . PREVIOUS OPRRATION HISTORY /n/ <br /> r A-D in �) d <br /> 7 . GENERAL SANITATION <br /> State any problems not, previously noted: <br /> 3 . POPULATION DENSTTY <br /> Appx. No . People per eq. mi . <br />