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1. SEWAQE <br /> Distance to Public Sewers Connection necessary: Yes ljo ' <br /> Does existing septic system comply with Ord. #549 : Yes Ao <br /> Unknown If no, explain: <br /> Describe septic installation to •be installed: <br /> 2. WATER SUPPLY <br /> Is wat supplied by private well : Yes � No Is well proper: <br /> Yeso State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No—,4,---�ample of well dater taken: Yes No.,.�--Date taken <br /> Results - Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licenaed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem- <br /> 4. <br /> roblem:4. FLY. MOSQUITO OR VECTOR POTEiNTTAL <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing : �-x" Additional <br /> facilities needed <br /> 6. PRFVIOfa OPERATION HISTO£Y / <br /> je <br /> 7 . GENERAL 5A«T_ TTON <br /> State any problems not prevlously noted : <br /> S . POPULATION DF,L4'"TTY <br /> Appx. No . People per act . mi . <br />