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1 <br /> SEWAGE -7 OGi <br /> Distance to Public Sewers Connection necessary: Yes Noz <br /> Does existing septic system comply with Ord . 0549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> 2 . MATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes U- No State deficiency : <br /> Does existing or porposed use make this well public water: Yes- <br /> No � <br /> esNo �.-' Sample of well water tarsen: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licenced scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . �L MOSQUITQ OR V CTO Zffja�TI� / <br /> State possible vector potential F& necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : _ Additional <br /> facilities needed <br /> 6 . PRFVTOQ2 OPERATION HISTORY / <br /> 7 . QEEr1,BAL SAPU 'lf�'_(-)U <br /> State any problems not previously noted: <br /> S . POPULATION DENSITY <br /> Appx. No . People per rq. mi . <br />