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r <br /> , <br /> 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 11, Sample 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 . =,,_ MOSQUITQ OR VEQTOR PQfrETlArl <br /> State- possible vector potentiftl necessary control: <br /> 5 . TOILET/BATH <br /> No. Fi location existing : _ <br /> Additional <br /> facilities needed _ <br /> 6 . PR .VIOTTS n +.RATIOP_ ZHisTngy <br /> 7 . GENERAL SANI'r '1,A 'I()N <br /> State any Problems not previously noted: <br /> 8 . POPULATION Dr t "��2I11 - <br /> Appx. No . People per rq . rr,i . <br />