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y <br /> 1 . SEWAGE <br /> Distance to Public Sewers /00 Connection necessary: Yes 4► No_ <br /> Does existing septic system comply with Ord. $1549 : Yeses No_ <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No—. Is well proper: <br /> Yes No State deficiency : <br /> Does existing or porposed use make this well public Water: Yes <br /> No Semple of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes /No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FILL,- MOSQUITO 0$ V Z 12T z2rMT?&Lt <br /> State- possible vector potentiitl necessary control . �f � <br /> 5 . TOILET/BATII FACILITES <br /> No . & location existing . �� Additional <br /> facilities needed _ <br /> 6 . PREVI0Q2 QPER,A'i IQN H ; =s <br /> s em' cr�.:.o <br /> 7 . O R NE R A L SA pLj `l,}�_'I t)N <br /> State any problems not previously noted:_ <br /> 8 . MaILLATION DENSTIX <br /> Appx. No . People per r_.q. m i . <br />