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1 SEWAGE <br /> Distance to Public Sewers —14M tO ` Connection necessary: Yes No x <br /> Does existing septic system comply with Ord. #549: Yes x No <br /> Describe septic installation to be installed <br /> 2 WATER SUPPLY <br /> Is water supplied by private well. Yes X No Is well proper: Yes k No <br /> State deficiency. <br /> •'� Com(-fs� (ill G1.1�,C�(YW� /L�.G� <br /> Does existing or proposed use make this well public water: Yes No X< Sample of well <br /> water taken: Yes No 1 Date taken Results <br /> Addii:torial information or comments: <br /> 3. GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No ?C Service Area No. <br /> Other proposed disposal method: <br /> Potential problems: <br /> 4 FLY. MOSQUITO. OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: PM �- <br /> TOILET/BATH FACILITIES <br /> No. & location existing: _ <br /> Additional facilities needed <br /> 6 PREVIOUS OPERATION HISTORY <br /> 160 <br /> yil�tit�d�7w ,,,�.F,� ►�-- <br /> 7 GENERAL SANITATION <br /> State any problems not previously noted: <br /> 8 POPULATION DENSITY <br /> Appx. number of people per square mile I <br />