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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No <br /> Does existing septic system comply with Ord. #549 : Yes y" No_ <br /> Unknown If no, explain: <br /> Describe septic installation to *be installed: --� - � - <br /> 2 . WATER SUPPLY <br /> Is water Bppplied by private welXe$ .� No Is well proper: <br /> Yes No_-L State deficiency : chi /f�-G <br /> ��od��'�i�,Y� �o�'r ill/�� Cao�2�.P� �c .fd��•��'F- -,-E� <br /> Does existing 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 No, Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . =, _ MOSQUITO QR VZ^TQ_ Mr E IAL <br /> State possible vector potential ?z necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: �� _ Additional <br /> facilities needed _ <br /> 6 . PRFy_IOITE OPERATION HISTORY <br /> 7 . GENERAL SA N I T.A:L <br /> State any problems not Previously noted : �6_- <br /> 8 . POPULATION DENST11 <br /> A p p x. No . People per 6q . r,,i <br />