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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes Nol� <br /> Does existing septic system comply with Ord . #549 : Yes . No_, <br /> Unknown If no, explain: <br /> Deecri ptic astallation to 'be installed: 457 <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes Ho> Is well proper: <br /> Yes. No State deficiency : <br /> Does existing or porposed use make this well public Water: Yes— <br /> No_� <br /> esNo_11� Sample of well water tarsen: Yes Nom Date to en_Y_ <br /> Results Additional information or commentsi �r,, <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes—V,,- No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem- <br /> 4 . <br /> roblem:4 . =L MOSQUITQ OR VEQTOR ECj rLET.IA,1.L <br /> State possible vector potentiftl 8z necessary control : ol!�-lyy <br /> 5 . TQILET/BATH FACILITES) <br /> No . & location existing: �;� _ Additional <br /> facilities needed _ <br /> 6 . PREVIMIS OPERATION HI Tn <br /> 7 . GENERAL SAPLIT,.g'22 <br /> State any problems not previously noted : ��. <br /> 8 . pn ILTIt�N DFtIY <br /> Appx. No . People per cq . r,,i . f" <br />