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1 . 5EWAGE <br /> Distance to Public Sewers ii Connection necessary: Yes ' No_ <br /> Does existing septic system comply with Ord. #549 : Yes 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 clo 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 tarsen: Yes No t 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 . ELIL MOSQUITO OR VZ^TQz2r1. <br /> State possible vector potentifil F.c necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: _ Additional <br /> facilities needed _ <br /> 6 . PREVIOM O ER-ATION HISTngy <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted : <br /> 8 . p0 1LATIOi1 Dr i4,3?Tv <br /> Appx. No . People per Rq . r;,i . '`�� � <br />