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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic syst comply with Ord. #549 : Yes No— <br /> Unknown If no, expl <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 /> 1 v � 5 - <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 commentsr s , ee <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No .,-,--- Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLY, MOSQUTTO ,OR VMQTOR PQ''r,NTT,&L <br /> State possible vector potential & necessa-^y control: <br /> 5 . TOILET/BATH FACTLIJES <br /> No. & location existing: - Additional <br /> facilities needed <br /> 6. PRF.VIQUa OPERATION HISTORY <br /> 7 . GENERAL SAITTIAT nN <br /> State any problems not previously noted- <br /> a . <br /> oted3 . POPULATTnN DFYSTTY <br /> Apex. No. People per so . mi. <br />