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i. EEKAGE <br /> Distance to Public Sewers _ Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord. #545 : Yes No— <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 2. HATER SUP <br /> Is water supplied. by private well : Yes No Is well proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make this well public anter: Yee <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. ELI, MOSQUITQ CSR VCCTnR POTENTIAL <br /> State possible vector potentiitl & necessary control - <br /> 5 . <br /> ontrol :5 . pup/BATH'aaunri <br /> No. €t location existing: � Additional <br /> facilities needed _ <br /> 6 . EREyions cPFR.ATQm HISInaX <br /> 7 . GENERAL SAP T�O <br /> State any problems not previously noted: <br /> 8 . ROPULATIQLf DF,' <br /> Appx. No. People .per ..aq'. mi . <br />