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t <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 /> -x-77 <br /> fa,e, a - s- 0 -%o a <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes v iia Is well proper: <br /> Yes.,E,,ft State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments V <br /> e <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. F.I.LY.L MOSQUITO OR VE^TO P )TE,NTIEILL <br /> State, possible vector potentiftl control : <br /> 5 . TOTLET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed J _ <br /> 6. PREVIOOS OPERATION HISTORY <br /> T^—)LT— e_� <br /> 7 . GENERAL SA11IT,ATON <br /> State any problems not previously noted:_ <br /> 3 . POPULATION IjrENSTT" <br /> APpx. No. People per 6q. mi. .Tz <br />