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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 /> Describe septic installation to 'be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes x iso Is well proper: <br /> Yes �` No State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> Nom,\ Sample of well water taken: Yes No Date taken <br /> Results - Additional information or comments <br /> 3 . TSE <br /> Licen d scavenger pick-up: Yes No Service Area N . <br /> Other p posed disposal method: <br /> Potential rob <br /> 4 . FLY nSo ^TMS p2MITIA.'" <br /> State possible vector potentiftl ez necessary con`�rol: <br /> 5 . TOILET/BATH FACILITES �\ <br /> No. & location existing : �� Additional <br /> facilities needed _ <br /> 6 . PREVIOUS CPLRATT0'Lj HISTO , <br /> 7 . CEN RAL SANTT,ATION <br /> State any problem"s not previously noted : <br /> 8 . POPULATI( N DF L `'T v <br /> Appx. No . People per act. mi . <br />