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i <br /> l • S_RWAG1 Connection necessary: Yes No_ <br /> Distance to Public Sewers <br /> Does existing septic system comply with Ord. #549 : Yes No— <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> I r <br /> 10 y <br /> Is w to supplied. b_� private well: Yes , i"o Is well proper: <br /> Yee o�.. State deficieneY: <br /> l <br /> Does e5.1z.tina or porposed use make this well publ c Water: Yes— <br /> No Sample of well water taken: Yes P10 Date taken A a <br /> Results Additional information or comments <br /> 4Z ✓ G "Y <br /> 3 . <br /> Licensed scavenger pick-up: Yes No Service Area No.. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4, FLY, MQSQUITQ OR ECTOR RO ENTIAL <br /> State possible vector potential Fg necessary control: <br /> 5, FACTLITEa <br /> No. & location existing: Additional <br /> facilities needed <br /> f 6PREVTOna DERRATION HISTORY <br /> eky <br /> State any problems not previously noted: <br /> 3 . BOP[lL611QN DENSITY <br /> Appx. No . People per sq,. mi. <br />