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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 ins .a3lation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : _ Yes No Is well proper: <br /> Yes No State deficiengy-4--- ` <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 & REFUSE <br /> Licensed scavenger pick-up: -Yes No Service Area No. <br /> Other proposed disposaltflod: <br /> Potential problem: <br /> 4 . EtLY.� MOSQUITO OR VE^TO pC,'rL- a1_T A,1 <br /> State possible vector potentiftl Fz necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: _ Additional <br /> facilities needed _ <br /> 6 . PREVIT S OP MA'i Oil HIST(1 r <br /> 7 . GENERAL SAtUI 'l�rl <br /> State any problems not previously noted : - <br /> 8 . <br /> oted : —s . pnptjLATIQN r,E ST I <br /> Appx . No . People per rq . r;;i. . <br />