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1 . SEWAGE ' �-- <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . #549 : Yes No— <br /> Unknown If no, explain: <br /> L_ c:5- <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: Yesl <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or cotr,ir,ents TSG ' <br /> ] �fA L ' <br /> 3 . GARBAGE & REFUSE c5 <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential proble r, : <br /> 4 . E � MOSQUITO OPV Z^.TQ PC'I'_E13TTALL <br /> State possible vector potential Fz necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : — Additional <br /> facilities needed _ <br /> 6 . PRFVIon3 O +.RATIOid HISTn r <br /> 7 . GENERAL S A IUTA'J'I ON <br /> State any problems not previously noted - <br /> 8 . <br /> oted :S . P= T l 1 ) ,1LLTjy. <br /> Appx . No . People per r-.q. mi . <br />