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1 . SHAG <br /> Distance to Public Sewers 4�1k+ Connection necessary: Yes No,_ <br /> Does existing septic system comply with Ord . #549 : Yes No_ <br /> Unknown If no, explain : <br /> Describe sep is installation to 'be installed: <br /> Z . 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 water: Yes <br /> No K _. Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBA.QE & EE.EisE <br /> Licensed scavenger pick-up: Yes. No Service Area No. <br /> Other proposed disposal method: vi" <br /> Potential problem.-___ n Vy l <br /> 4. FLY. MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potentirtl & necessary control: �4y <br /> 5 . TOILET/BATH FA(,,ILITFa tv <br /> No. do location existing : Additional <br /> facilities needed <br /> 5 . PRRVIOU2 OPERATION HTSTORX <br /> 7 . GENERAL. SANTTATTQN <br /> State any prot-)lems not previously noted : n u� <br /> S . PORULA T TON DENSTIY <br /> Appx. No . PeoD le per oq. mi. <br />