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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 /> i ���` ; <br /> Describe septic installation to be installed: <br /> 2. MATER SUPPLY <br /> Is water supplied by private well: Yes No Is well proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make this well public water: Yes <br /> No Semple of well water tarsen: 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 . 1 MOSQUITO QR V M^T(_) P2!'r.,ET_T <br /> State possible vector potentiitl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : _ Additional <br /> facilities needed _ <br /> 6 . PRFVT0QS OPERATION RAATTION H=, / <br /> 7 . GRNERAL SA1U!AT1_(_) <br /> State any problems not previously noted: <br /> 8 . 22alLATION D i `'T " <br /> Appx. No . People per rq . mi. •L� <br />