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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 installation to 'be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes flo Is well proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water tarsen: 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. g Aj.,_ MOSQUITO OR EQTOR PS'rIa TIAL <br /> State possible vector potentiftl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing : — Additional <br /> facilities needed _ <br /> 6 . PREVI0112 OPERATIC_ NH=Tn <br /> 7 . GENERAL SAPLT,,AIJU N <br /> State any problems not Previously noted : — <br /> S . <br /> oted :S . EOPU ,ATIO14 TEEN ` I v <br /> Appx. No . People per 6q . mi . <br />