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1 . SEWS <br /> Distance to Public Sewers Connection necessary: Yes No,4_� <br /> Does existing septic system comply ith Ord. #549 : Yes No_. <br /> Unknown If no, explain: ��9�' <br /> Describe septic installation to 'be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well: Ye i*10_2�,_ Is well proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make this well public water: Yes <br /> No�- Sample of well water taken: Yes Nom; 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 <br /> ethod:Potential problem: <br /> 4 . FLY. MOSQUITO OR Vr1.QT0R PO'r]:NTTA , <br /> State possible vector potential & necessary control: L <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: 4_:f_ Additional <br /> / <br /> facilities needed - <br /> 6. PREVIOnSry OPERATION HISTORY <br /> 7 . GENERAL SANITA TQN <br /> State any problems not previously noted: <br /> 3 . POPULATION DENSITY <br /> Appx. No . People per eq. <br />