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i <br /> r• <br /> 1 . SEWAGE. <br /> Distance. to Public Sewers /1 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 No 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 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 . ELY. MQSOUITO OR_y_1i: ) ECTERLIAL <br /> State possible vector potentiFtl Ri necessary control : <br /> 5 . IL,ET/BATH FACILIi. <br /> No. & location existing : -:ting : _ ___ Additional <br /> facilities needed_v_ <br /> 6 . PREVIOUS OPERATION H-TBX <br /> 7 . GE�iERAL SANI'!'A`i' �N. <br /> State any problems not previously rioted : <br /> HIT�JT11QR-M43J-TY- <br /> Appx . No . People per sq . mi. <br />