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1 . SRWAGF6 <br /> Distance to Public Sewers Connection necessary: Yee 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 coo Is well proper: <br /> Yes No State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No , Sample of wel:: water taken: Yes No Date taken <br /> Results Additonal information or comments <br /> 3 . GARBAGE & REFUSR <br /> Licensed scavenger pick-up: Yee No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem:-- <br /> 4 . FLY, MOSOUTTO-D-B V TOR POTENTIAL <br /> State possible vector potentiztl & necessary control: <br /> 5 . Tn_I�1BATH FA(-,ILjTFa <br /> No . ec location existing : Additional <br /> facilities needed <br /> 6. PRRVTOUS OFERATION HISTORY <br /> 7 . CENRRA . SANITATTON <br /> State any problems not previously noted : <br /> 3 . POPULATION DE aT <br /> APPx. No . People per ca . mi. - - - - _ - - <br />