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SEWACIF <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 `/ No Is well proper: <br /> Yes`x- No State deficiency: <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of Nell water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 , GARBAGE & REFUST <br /> Licenaed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: P,,,j ' <br /> 4 . FLY. MOSQUTTO OR Vr;CTnR P,QTENTTA <br /> State possible vector potenticil F.c necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: z- Additional <br /> facilities needed <br /> S . PRF�yI aS CPCRjATION HISTngy <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted: <br /> S . POPULATION DENSITY <br /> Appx. No. People per eq mi ,L ° <br />