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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 SUPPI,I M' i <br /> Is water oupplied by private well : Yes oo Is well proper: <br /> Yes t�AM� State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water tarsen: Yes Ncy .''Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: YesArea No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . =,._ MQSQUITQ OR V E^TO EL)f a TI L <br /> State possible vector potentiFtl & necessary control : <br /> 5 . TOILET/BATH TOILET/BATHFACILITES <br /> No . ec location existing : - Additional <br /> facilities needed _ <br /> 6 . PREV I OM OPERATION HISTORY <br /> 7 . GENERAL SAP111 'l,A ' -O <br /> State any problems not previously-- noted :- <br /> 8 . <br /> oted :_8 . pOPULATION DEN `'I Y <br /> Appx . No . People per 6q . mi . <br />