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i <br /> 1 . SFS <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 septic installation to be installed: <br /> 2 . MATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yee No State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water tarsen: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REEUSR <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem- <br /> 4 . FLY—,- MOSQUITO OR <br /> State possible vector potentiftl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: _ Additional <br /> facilities needed _ <br /> 6 . PREVIQQS OPERATION HISTORY <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted : - <br /> 8 . <br /> oted : _8 . EOPULATIO14 DEda?TY <br /> Appx. No . People per 6q . r;,i . <br />