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J <br /> 1 . SEWAGF <br /> Distance to Public Sewers /UConnection necessary: Yes_ No <br /> Does existing septic system comply with Ord . #549 : Yes,,�ZNo_ <br /> Unknown If no, explain: <br /> (f/2 3164) <br /> Describe septic installation to 'be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes__:: No State def iciency : <br /> Does existing or porposed use make- this well public water: Yes <br /> No Sample of well water ta'r;en: Yes No :i Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licena scavenger pick-up: Yes No Service Area No. <br /> Other pro'p' sed disposal method: <br /> Potential p blew: <br /> 4 . F11'1_ Sc C) ^.TOS PS)'f1 t1, TIAI, <br /> State- possible vE tar potentiFtl necessary control : <br /> 5 . TQILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed 7 _ <br /> 6 . "'`VIOf]S APER ' t <br /> 7 . GENERAL SAP T <br /> State any prob m: not previously noted:_ <br /> 3 . O ( /)EILEDiTY <br /> Appx. No . -People per cq. mi . <br />