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d <br /> 1. <br /> Distance to Public Sewers �r�' Connection necessary: Yes No`� <br /> Does existing septic system comply with Ord . #549 : Yes No.� <br /> r Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 2. WATER SUPPLY <br /> Is Hater supplied. by private well : Yes Llo V- Is well proper: <br /> Yes No State deficiency: <br /> DoesxistinB or porposed use make this well public Water: Yes <br /> No Sample of well mater taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GABBAGE <br /> Licenaed scavenger pick-up: Yes ✓ No Service Area No. <br /> Other proposed disposal mejhod: , <br /> Potential problem: <br /> 4. FLY._ MOSQUITO OR VFQT�fRPQ' -rNTIAL <br /> State possible vector potential & necessary control: <br /> i <br /> 5 . TQTLETZBATH t rTUTES <br /> � k <br /> No. & location existing: Additional <br /> facilities needed—� <br /> 6. PREVInRS CI'TsRATIc��i ,�jjSTnRY <br /> 7. GENERAL SANITAXIM �]r <br /> State any problems not previously noted: /I - •- <br /> 4 <br /> aa —• n -Tam.—w .��...^.�•. -r• ..r.�. �// <br /> V • 1 US Y <br /> Appx. No. People per . q. mi . C/ � <br /> i <br /> n <br />