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1 . EEWAGE <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 Nod 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 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 . FAL MOSQUITQ QR V ^ ) PC'f ENTIAL <br /> State possible vector potentiFtl Fz necessary control : <br /> 5 . TQTLET/BATH FACT_L�ITES <br /> No . & location existing : Additional <br /> facilities needed _ <br /> 6 . PRE�VIOUS OPERATION HISTORY <br /> 7 . QEN +,RAL SAPII'r 'lfi 'ION <br /> State any problem: not Previously noted-- <br /> 8 . <br /> oted:_8 . POPULATIO14 DFN,zTly <br /> Appy. No . People per rq. mi. . <br />