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r <br /> 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 /> Describ septic installation to be installed: <br /> S <br /> 2 . WATER 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 taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . )jE <br /> Licen\edscavenger pick-up: Yes No Service Area No. <br /> Otheed disposal method : <br /> Potenoblem: <br /> 4 . FLY Y 'QPStUNTIAL <br /> State possib vector potentiftl & necessary control : <br /> 5 . TQILET/BATH FACI I <br /> No . & location exist,i __.. Additional <br /> /_ <br /> facilities needed <br /> 6 . PREVIOUS OPE 0 <br /> —z <br /> 7 . GFNFRAL ^/ITTATION <br /> State a - 7 problems not previously note <br /> 8 . <br /> ppx. No . People per r_:q. mi.- <br />