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T <br /> 1 . SEWAGE� <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord. 0549 : 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: Y s ' No Is well proper: <br /> Yes_ No State ceticiency: �°����j` �%� <br /> 72�EO�Y4W, ­-, —f`3C—4. C �t/i�y6�s 6c� e s 9G F1�F i�r cr.G fit/ /, <br /> .f�h�i6e io%✓ r�.G.�oy�9�� a -o D� / /dam �,cr� 4Q� �' �f�'c�a���ai/G�if` <br /> o enc ..YA�H e�I, ,lt?.r�lf �� 4//i.G n/�'� �G/-,o yo-o,�"�EEO.PE/�y,,ff7.4C oG9 io.��✓F!/o�+//J/�oloy-ose-y6/ <br /> Does ex 1s� �ngor`porPosec u e make this well public water: Yes- <br /> No---t <br /> esNo_t Sample of -well water taken: Yes No , Date taken <br /> Rg�isults� Additional information or c mment <br /> Dfr7 r !�/f{i . o�y �i/ s?a�— oyo G� /it 6ioc���f f c.E' -r nG�if �7'l0 �O <br /> �4.►�/,CFf��o�n�Fc.f Y 9.1v� / <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem- <br /> 4 . <br /> roblem:4 . =. MOSQUITQ OR VC) E,L)fZNTIAL <br /> State possible vector potentiftl & necessary control <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: - Additional <br /> facilities needed _ <br /> 6 . PREVTOQ2 OPERATION HISTORY <br /> 7 . GENERAL SAIJITATION <br /> State any problems not previously noted : <br /> 8 . POPULATION DENSITY <br /> Appx. No . People per oq , r,i.��.l���l�<<c �.� ✓�� .� <br />