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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No,,,. <br /> Does existing septic system comply with Ord. #549 : Yes No_ <br /> Unknown If no, explain : <br /> P ,1 <br /> Describe septic installation to be installed: <br /> i <br /> 2 . WATER SUPI'I,Y <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes No State deficiency : A Q <br /> I _ <br /> IV � <br /> Doe e isting or porposed use make this well public water: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Res lts Additional information or comments <br /> 3 . TCS <br /> Li need scavenger pick-up: Yes No Service Area No—Z <br /> Otheil.,proposed disposal method : <br /> Potenti 1 problem: _ <br /> 4 • FLY � Y �' PS�'LLTIAL <br /> State possib vector potenti,,t.l & necessary-tontrol : <br /> 5 . TQILET/BATH FACILI7� <br /> No. & location existing: _ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HIAEMRY <br /> 7 . NF AL ZITTATTON <br /> State ny problems not previously noted: _ <br /> Atpp. . No. People per sq. mi .- <br />