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}j • <br /> 1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No L' <br /> Does exist ng 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 b,,7 pr. ivate well : Yes � No Is well proper: <br /> Yes No-- State deficiency :—!-- <br /> Does existing or p"posed use make this well pu lic water: Yes <br /> Na Sample of well water taken: es__ No Date taken <br /> Results Additional information or cGlr�Itl .ntc <br /> 3 . AGE & REFUSE <br /> Liceed scavenger pick-up: Yes No Service Area No . <br /> Other oposed disposal method : <br /> Potentia problem: --4 . ELYM " T QBy ;TS�ii_ '�I3T� Z1 <br /> State possib 'vector. potentiFtl & neceso/ztry control : <br /> 5 . T i LET/BATH FAC I LU' 2 \ <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . PREVIOUS OPE-L-TION 0 <br /> 7 . GENE SANI'r 11 <br /> State any proble s not previouL-,ly noted:'. — <br /> Appx . No ./People per sq . mi .- <br /> I <br />