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i <br /> f <br /> f.. SEWAa s <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 STEELY <br /> Is mater suppliedby private well : Yes iso Is well proper: <br /> Yes No State deficiency: <br /> i <br /> Does existing or porposed use make this well public Water: Yes <br /> Nom. Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . rABBAGu_&_RFF'USS <br /> Licensed scavenger pick-up: Yes Na Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. Fr,YL. MOSt [IITn �R V O— 2 <br /> State possible vector potential necessary control: <br /> a . TOILEUBATH <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVIO " nPrRATInN HISIORY <br /> - i <br /> s <br /> 7. <br /> State any problems not previously noted: <br /> 3 . 'PORTILATIQU `I <br /> Appx, No . People per coq. mi � <br /> d <br /> I <br />