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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 /> Describe septic installation to 'be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is dell proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make this well public water: Yes <br /> Nom_ Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REEUSR <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. MOSQUITQ OR V MT-C EC)M TATS <br /> State possible vector potentiFtl ?.c necessary control : . , . <br /> 5 . TOTLET/BATH FACILITES) '0 e <br /> No. & location existing:'--7 � F� � Addi nal <br /> facilities needed _ <br /> 6 . PREVTOT7E r_,PERATION HISTO <br /> 7 . GENERAL SAPU A J(—) <br /> State any problems not previously noted : �� � F�-� <br /> 8 . pop[ILATION pENSTIX <br /> Appx. No . People per 6q. mi <br />