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1 • 5J:tIIAGF <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 we'll : Yes No Is well proper: <br /> Yes No State deficiency: <br /> Does xisting or porposed use make this well public water: Yes <br /> No -7 Sample of well water tarsen: Yes Nom 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 problem: <br /> 4 . FAL MOSQUITQ OR VEC'TO PS)'fl;ETTAL <br /> State possible vector potentiitl necessary control : <br /> 5 . TOTLETZEATTI FACILITES <br /> No . & location existing:_ Additional <br /> facilities needed _ <br /> 6 . PREVTOPS OPERATION HISTORY <br /> 7 . GENERAL SAIUMAILON <br /> State any problems not previously noted : <br /> 3 . POPULATION DF ?Tv � <br /> r <br /> Appx . No . People per oq. rr,i.'O6iric�/,��,� <br />