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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes " No K <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 SUPPLY <br /> Is water supplied by private well : Yes No Is wellroper: <br /> Yes-- /No-/ State deficiency - <br /> AV <br /> vZ <br /> ^.Pc w"S' "•'^I'.•r•.. .. ,,,-,. f'�s'. .• f,. �"+' -' I'c%!' 4! '�� e..rr,R''tt �,:� ,r....•, .r '.",K.�i�-,�l�7-,�•¢G Ty-���f" <br /> Does exfsffng 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 . EL S MO fUITOL-OE–Y ) ZSi'r�,.NITAL <br /> State possible vector potential & necessary control : <br /> 5 . TQILET/BATH FACILITS <br /> No. & location existing : Additional <br /> facilities needed _ <br /> 6 . PREVIQU2 OPERATION HIST= <br /> 7 . GENERAL SANI'EAjJ_0_N. <br /> State any pro blerrns not previously noted : <br /> 8 . POPULATIQN tENaLTY <br /> Appx . No. People per sq. mi <br />