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' w <br /> 1 . SEWAGF <br /> Distance to Public Sewers Connection necessary: Yes No <br /> Does existing septic system comply with Ord. #549 : Yeses No_ <br /> Unknown If no, explain: <br /> De cribe sept c nstallption to 'be installed: <br /> T <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes . No Is well proper: <br /> Yes X' No State deficiency: <br /> Does existing or porposed use make this well public crater: Yes <br /> No Semple of well water tarsen: Yes No -,<' Date <br /> aa�en <br /> Results Additional information or comments Ate% -� <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes--4- No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> i <br /> 4 . E.L�� MOSQUITQ QBy '11T_ z2r T <br /> State possible vector potentiftl ez necessary control: -� <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : — Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPER.ATIOfL HH 5 <br /> 7 . GENERAL SAM ATT()N <br /> State any problem: not previously noted: — <br /> I <br /> 3 . F'O ' iLATION DE STIy II <br /> Appx. No . People per sq. <br />