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V <br /> 1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes NQS <br /> Does existing septic system comply with Ord. #549 : Yeg­E,7_77 No_ <br /> Unknown If no, explain : <br /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is wr supplied by private well : Yes No Is well proper: <br /> Yes-,Z, No State deficiency : _ <br /> Does existing or purposed 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 . FLY, MOSQUITO OR =­ } P_}'I'=Al r <br /> State possible vector potential & necessary control : <br /> 5 . TQT.LET/BATH FACILITES <br /> No . & location existing : "__/ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> ZX.�,, <br /> 7 . GENERAL SAtdITA.7,'LM <br /> State any problems not previously noted: �o�lt <br /> 8 . <br /> Apex. No . People per sq. mi. W"'Pies` <br />