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1 . SL'tWAGF k,/ r F <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 /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes tdo Is well proper: <br /> Yes � No State deficiency : <br /> Does eXisting or porposed use make this well public crater: Yes <br /> No " Semple 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: AUl` <br /> 4 . ELLY_L MOSQUITO QR VEQTOR PQfLNj_T .TL <br /> State possible vector potentiftl Pz necessary control : <br /> 5 . TQILET/BATH FACILITES <br /> No . & location existing: Additional <br /> facilities needed _ <br /> 6 . PREVInUs OPI`R.ATinN HISTn ; <br /> 7 . GENERAL SAPU'r '1=A 'SO <br /> State any problems riot previously noted : _ <br /> 3 . EOPIJLATIO14E �STTY <br /> Appx. No . People per rq . mi . �' <br />