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i <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 sppti insta lotion to ' e �nstaj jed: <br /> 2 . WATER SUPPLY <br /> Is wa er supplied by private ;cell: Yes iso Is well proper.: <br /> Yes No State deficiency : �� o <br /> 9J�a.4>`' vE•'� ��i/9-F F 6 e i (p �7' 6 �'o q� c -�S�1',a�J�i/F v N r'� <br /> Does xisting 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 <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes-,L No Service Area No . <br /> Other proposed disposa; method : <br /> Potential problem : <br /> 4 . EL�� mosg T TO Qg VE^Tn PL'f , TT T <br /> State possible vector potentiftl necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed _ <br /> 6 . PRF.VTona (-,pFgATjnj4 HISTOF•Y <br /> 7 . GENERAL 'Q III'T,A`1'ION <br /> State any problems not previously noted: <br /> 8 . POPULATION DENSTI <br /> A p p x . No . People per sq . mi . ��/�'y-C/U'����s�.DF�✓ ,` <br />