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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 17 No_ <br /> Unknown If no, explain: <br /> 7U - 6q-3 <br /> Describe se is installation to be installed: <br /> s' <br /> 2 . WATER SUPPLY <br /> Is w r supplied by private well : Yes -LL�- No Is well proper: <br /> Yes No State deficiency : — <br /> Does e?,, ting or porposed use make this well p�ic 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 No Service Area No . <br /> Other propos disposal method: <br /> Potential prob et7i: _ <br /> 4 . FLS OSF�UI'�0 Q '^. 'IO'rNTIAL <br /> State possible vec rr potential & necessary control: <br /> 77 <br /> 5 . TQILET/BATH FACILIlaa <br /> No. & location existing: Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY A <br /> 7 . GENERAL SANITp=M <br /> State any problems k"ot previou.sly rioted: Y _ <br /> S . POPULATIO 7a Et Y <br /> Appx. No . Peo'ple per sq. mi .- <br />