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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 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 flo Is well proper: <br /> Yes Na State deficiency : <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 & REFUSR <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem,: <br /> 4 . =L MOSQUITO OR VECTOR PC'fLEZjAL <br /> State possible vector potentiFtl & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing : _ Additional <br /> facilities needed _ <br /> 6 . PR .VInf12 CPERAT1 14Hj.,^5TOF_Y <br /> 7 . Q2Nr,,EAL SArIIT 'l,�H <br /> State any problem^ not previously noted :- <br /> 8 . P- > iLATION DFN `'T y <br /> Appx. No . People per sq. mi . <br />