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1 . <br /> Distance to Public Sewers 1� Connection necessary : Yes No_ <br /> Does existing septic system comply with Ord . #549 : `les No_ <br /> Unknown If no, explain : <br /> Describe septic installation to be installed: <br /> 2. NATER SUPPLY <br /> Is Water supplied by private well : Yes No—LlIE well proper: <br /> Yes No State def4 ciency: <br /> Does existing or porposed use make this well public Water: Yes <br /> No- Sample of well water taken: Yes No �/ Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REF 1SE <br /> Licensed scavenger p..ck-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLY, MOSQUITO CSR VEQTOR 20'rENTI L <br /> State possible vector. potential & necessary control: <br /> 5 . TOILET/BATH FAr.T ,rTES <br /> No. & location existing: �� Additional <br /> facilities needed <br /> S. PRRVIonB C 4RAT nN HTsTORY / <br /> 7 . GENERA , SANTTATTON <br /> State any problems not previously noted: <br /> 3 , POPULATIO14 DFNSTTX <br /> Appx . No . People per ca . mi <br />