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1 . AGE <br /> Distance to Public Sewers LW=- Connection necessary : Yes No— <br /> Does existing septic system comply with Ord . #549 : Yes No— <br /> Unknown If no, explain: <br /> Describe, septic install ion to be insta]l9d: <br /> Z . WATER SUPPLY <br /> Is water supplied by private well : Yes ,� No Is well proper: <br /> Yeses No State deficiency : <br /> Does existing or porposed use make this well public Water: Yes <br /> No Sample of well water taken: Yea No Date taken <br /> Results--� Additional information or compen s <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No-14 Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLYL MOSQUITQ OR V CTO PS)TTt�TT_AL <br /> State- possible vector potentiftl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & locution existing. --_ Additional <br /> facilities needed _ <br /> 6 . PRFVI0QS O ERATTON HLT ) <br /> 7 . GFNFRAL SAIJIT TION <br /> State any problems not previously noted : <br /> 8 . P(-) ' 111ATIQN D i ,31TV <br /> A p p x . No . P e a p 1e per 6q <br />