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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes ' 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 ✓, No Is well proper: <br /> Yes ✓No State deficiency : <br /> Does existing or porposed use make this well public crater: Yes <br /> No Sample of well water taken : Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes ` No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . EIY_.1- MOSQUITQ OR VV Z;Thr psi'r ,NTTAL <br /> State possible vector potentifcl ?z necessary control : <br /> Nloo r .8 <br /> 5 . TOOL .T/BATH FAC ,TTFS <br /> No . & location existing : _ Additional <br /> facilities needed _ <br /> 6 . PRFVIor1S npER.ATIO[1 HTSTnFjy <br /> 7 . GENERAL SA1=ATJ_()N <br /> State any problem do t previously noted: - <br /> 8 . <br /> oted: _S . P2 ' )CATION Dr i 11. <br /> Appx . No . People per sq. rai . <br />