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1 . SEWAGF <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 se tic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes-'4- No State deficiency : <br /> Does existing or porposed use make this wellpublic water: Yes <br /> No '_ Sample of well water taken: Yes No� Date taken <br /> Results Additional information /or comments°? o' ,- <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 OR vEQTOR POrL <br /> State possible vector potentiftl ?.c necessary control :/ <br /> 5 . TO ."T/ TA H FACILITES <br /> No. & location existing: Additional <br /> facilities needed _ <br /> 6 . PREyIOU,^ OPERATION HIST(i ( <br /> 7 . GENERAL SA111! 'l.A 'I()N <br /> State any problem; not previously noted : <br /> 3 . POPUjATIO14 DENSTIAv L <br /> Appx . No . People per 6q . m i . <br />