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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 Pio Is tirell proper: <br /> Yes No State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> Na Semple of well water taken: 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 problcir,: <br /> 4. ElLy_L MosoujTn QR V Z2, _T_c ZC)rjaTTAL <br /> State possible vector potentiitl & necessary control : <br /> 5 . TOILET/BATII FACIIsI.TFS <br /> No . & location existing: _ Additional <br /> facilities needed _ <br /> 6 . PREVTODa OPERATION J- T= <br /> 7 . O RN .RAL EAPU.TLTI-oN <br /> State any problems not prevlou Io, noted : _ <br /> 8 . M ' ILATION DENTl <br /> Appx. No . People per 6q . mi . <br />