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1 . S.L'f9.AGE <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 tq be InstaAled: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes No__ State deficiency : _ <br /> 4 � <br /> Does existing or purposed 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 No Service Area No . <br /> Other proppsed disposal method: <br /> Potential problem: <br /> 4 . ELIC0� SQU I T�aQE�V I;; ) PS)T_TMT. A1L- -- �. <br /> State possible vectgr potentia & necessary control : <br /> Ii <br /> 5 . TQILETrBATH FACILITY <br /> No. & location existing : ' Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION H_I.�J <br /> 7 . GENERAL SANIM.TI N <br /> State any problems not previously noted: <br /> 8 . <br /> Appx. No. People per sq. mi ._ <br />