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r . <br /> 1 . S "WAGF <br /> Distance to Public Sewers - Connection necessary: Yes No-4 <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 No_T 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 tat;en: 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 . FAL MOSQUITO OR VEQTOR PQ frajTj11u <br /> State possible vector potentiFtl necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: — Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPE-RATION HIST=i <br /> 7 . GENERAL 2A1d! `lam '3��N <br /> State any problems not prev lou sly rioted : ��� <br /> 3 . P_OPULATIO14 DE NST11 � <br /> Appx. No. People per cq . m i . ' <br />