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1 . SEWAGF <br /> Distance to Public Sewers Connection necessary: Yes Nom <br /> Does existing septic system comply with Ord . 0549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installatiop to 'be installed: <br /> o n_vrJ <br /> 2 . WATER SUPPLY <br /> Is w er supplied by private well : Yes X No Is well proper: <br /> Yee. No State deficiency: <br /> Doe existing or porposed use make this well public water: Yes <br /> NoSample of well water taken: Yes No_�_f Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REF <br /> Licensed scaven er pick-up: Yes No Service Area No. <br /> Other proposed d poral method: <br /> Potential problem: <br /> 4 . FLY . MOSQUITO QR V PLf ENTIAL <br /> State possible vector'�otentittl & necese ry control: <br /> 5 . TnTT.F.T/BATH FACTLIT •S <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PR,EVIO112 OPERATION HISTORY <br /> 7 . GENERAL SA14IIATTON <br /> State any problems /npreviously noted : <br /> 8 . POPULATION DELISTIv, <br /> Appx . No . People per oq . mi . <br />