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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 /> Describe septic i stallation to be installed: Pf <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes ')--" No State deficiency: _ <br /> Does existing or porposed use make this well public water: Yes <br /> NoSample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . REFUSE <br /> ' Li c used scavenger pick-up: Yes No Service Area No. <br /> Othe proposed disposal method: <br /> Potent al problem: <br /> 4. FLYSSQ ITO OR Y ' P.Ci'EENTIAL <br /> State poss Nle vector potential. & necessary control: <br /> 5 . TQILET/BATH FACIA' <br /> No. & location existiAdditional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SAKI' " f. <br /> State any pro . ems not previously rioted: <br /> 8 . POP Ui.ATItl14 DE11=11 <br /> Appx. No . People per sq . mi ._ <br />