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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 se is installation to be installed: <br /> 2 . MATER SUPPLY <br /> Is water supplied by private well : Yes Llo 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 taken: Yes No Date taken <br /> Results Additional information or comments eo 1.4 -.N:%7-,Ae7 <br /> Licensed scavenger pick-up: Yes No Service-Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . =.,- MOSQUITO OR V M^.TO EC)M IAL <br /> State possible vector potentiFtl ?.c necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . ec location existing: ,..= Additional <br /> facilities needed- <br /> 6 . <br /> eeded _ <br /> 6 . PRFVIQQa QPER.ATIQN H=n r <br /> _l f h! <br /> 7 . GFNERAL SA 11!A]'ION <br /> State any pro'bleins. not previously noted : - <br /> 3 . <br /> oted : _3 . POPULATION DENSTIv <br /> Appy. No . People per cq . mi . <br />