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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 /> K C— r <br /> 2. MATER SUPPLY <br /> Is water supplied by private well : Yes No Is dell proper: <br /> Yes No State deficiency : <br /> Does existing or porposed use make this well public water: Yes r <br /> No 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 . =.,- Mosoui O OR V za--o Ec)MNTIAL, <br /> State possible vector potentiftl necessary control - <br /> NUNvGN-f <br /> 5 , TOILET/BATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed _ <br /> 6 . PREVIOiTS OPERATION HISTQRX <br /> 7 . QENERAL SAPIIT '1,A 'ION <br /> State any problem; not previously rioted: <br /> 8 . F-OPULATION DEN SITX / <br /> Appx. No , People per rq . mi . <br />