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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 /> 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 deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water taken: Yes No Date take <br /> Results Additional information or comments <br /> 3 . GARBAGE €i REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . EILYLL MOSQUITQ OR V Z2.TO EL)M ?LL <br /> State possible vector potentiFtl & necessary control : <- -% <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: _ Additional <br /> facilities needed _ <br /> 6 . PREVIOOS OPER.ATIntd H=, <br /> 7 . GENERAL SAPJIT '1,A 'ION <br /> State any problems not previously noted : <br /> 3 . POPULATION L)Ft ST 'y <br /> Appx. No . People per 6q . T"I.t . <br />