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1 <br /> 1 . SEWAGE �,. <br /> Distance to Public Sewers I� Connection necessary : Yes No ' <br /> Does existing septic system comply with Ord . #549 : Yes Nollz <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 / No State deflciency : — <br /> Does existing or porposed use make this well ptkblic water: Yes <br /> No ' Sample of well water taken: Yes No .` Date taken <br /> Results Additional information or comments ad\4 i W, f ! kit <br /> V.1 v v\ vwA,S�, S" <br /> r'S r Au k-'' e .0 (L�L v ��� r1 I�o� '_P'W V_ �Z� ,ata to IV <br /> 3 . GARBAGE & REFUSE �^ f <br /> Licensed scavenger pick-up: Yes )e No Service Area No. <br /> Other proposed disposal method : <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR M ) ECME TIAL <br /> State possible vector potential & necessary control : <br /> 5 . TQILET/BATH FACILI7T <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> Z <br /> 7 . GENERAL SANITa <br /> State any problems not previously noted: — <br /> S . <br /> oted: -3 . POPULATION DEASITY <br /> Appx. No . People per sq . mi . _ <br />