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f T <br /> Distance to Public Sewers Connection necessary: Yes No_ <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 . WATER SUPPLY <br /> Is water supplied by private well : s No Is well proper: <br /> Yes No State deficiency: , <br /> i <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water taken: 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 . <br /> roblem:4 . FLY, MOSQUITQ CSR VM TnR BQ'rENTTAL <br /> State possible vector potentiftl & necessary control: <br /> 5 . TOILET/BATH FACILiITFS <br /> No . & location existing: Additional <br /> facilities needed <br /> 6 . PRFVTons opERATToN HTST�RY <br /> _ /r <br /> �4C421,'f <br /> 7 . GENERAL SAN TATT-ON <br /> State any problems not previously noted: <br /> 3 . POPULATI014 DEQ Ste`-'_ <br /> Appx. No. People per sq. mi . <br />