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i . S E W A G <br /> Distance to Public Sewers �� Connection necessary: Yes No_ <br /> Does existi 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 V No Is well proper: <br /> Yes Noy State deficiency : <br /> Does e sting or porposed use make this well pub <br /> bc water: Yes <br /> No V Sample of well water taken: Yes No ,✓/ Date taken <br /> Results Additional information or comments <br /> 3 . GARB & REFUSE <br /> License scavenger pick-up: Yes No Service:-Area No. <br /> Other pro sed disposal method: <br /> Potential p blem : i <br /> 4 . 0^G UTTO VECTOR / <br /> State possiblector potential & r/1 .ese1ary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION a <br /> 7 . GENERAL SANT TTON <br /> State anyp oblems not previously noted: <br /> 8 . POPULATION DENSITY <br /> Appx. No . People per sq . mi . <br />