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1 . SSE <br /> Distance to Public Sewers a Connection necessary: Yes No - <br /> Does existing septic system comply with Ord . #549 : Yes No_ <br /> Unknown If no, explain: <br /> r .I rbc,+ cz 4 .2 -off <br /> Describeeptic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is wa r supplied by private well : Yes 110 Is well proper: <br /> Yes No State deficiency: <br /> Does e isting 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 & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem- <br /> 4 . <br /> roblem:4 . FLY. MOSQUITO OR V Zj;QTnR ENT I AL <br /> State possible vector potentiftl & necessary control: <br /> 5 . TOILET/BATH ,EACIjiITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PRFVTOnS OPRRATTON HISTORY <br /> 7 . GENERAL SANIIATION <br /> State any problems not previously noted: <br /> 3 . PO I ,ATION DENSITY <br /> Appx. No. People per eq. mi. <br />