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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes N61_�_ <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 )L No Is well proper: <br /> Yes No State deficiency - _— <br /> AZA-22 <br /> Does existing or porposed use make this well public water: Yes/ <br /> Na 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 . FLYS MOSQUITO OR. Y , C) PS)'MNTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TQILET/BATH Ijt,IL,T'31. <br /> No . & location existing : ____ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPER®TION HISTORY <br /> 7 . GENERAL SANITALT-CM <br /> Sts.te any problemr not previously noted: .+ _ <br /> 8 . P OPULATIM4 ) k ITV <br /> Appx. No . People per sq. mi .___ <br />