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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 /> �..�.. <br /> dtASb /r - � * � - ? <br /> Discrlbe septic ly <br /> installation to be installed : <br /> C� �m <br /> T <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yeses No Is well proper: <br /> Yes_ State deficiency : <br /> .�XT .t+>i'. ].-' / /` _C'�_� l! t Li�c..1/: P��J V7".+� l�I� ✓r �i..oF'".. <br /> Does existing or purposed use make this well public: water: Yes <br /> No ✓ Sample of well water taken: Yes No v Date taken <br /> Results �, 5 nAd/d�/itional information or comments � <br /> eyv a. <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: _ <br /> 4 . FLIL MOSQUITO OR y ; L) ECM TIAL <br /> _ State possible vector potential & necessary control : <br /> h r ` 0/ ra- 1i 1 !✓ ICJn j; _ � S G 2 S ?� ci 4 ? � � ? � 5 f 2/�/ O,_i @� G1� <br /> 5 . TQILETJBATH FACILITES <br /> No . & location existing : ___ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SAKI' AI_Jt_�N. <br /> State any problems not previously noted: ___ <br /> 8 . FOPULATIQN DENSITY —_ <br /> Appx. No . People per sq. mi . _ <br />