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Co <br /> SEWAG <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 /> Describe septic installation to be installed: <br /> 2 . MATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes__/,---No_ State deficiency : <br /> Does existing or porposed use make this well public water: Yes �- <br /> No Sample of well water tarsen: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . =,_ MOSQUITQ OR V E^.TO) ZC)fLN <br /> State possible vector potentiftl necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: — Additional <br /> facilities needed _ <br /> 6 . PRE�V_Tons opEgATIO[Z HISTO£,Y <br /> 7 . GENERAL SAtJITAjC) --. <br /> State any problems not previously noted: - <br /> 8 . <br /> oted: _8 . EOPULATION hr i `'T X -. <br /> Appx. No . People per rq . mi . <br /> 77 <br />