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1 2rWGR <br /> Distance to Public Seders 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. NATER S MLY <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 taster: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licenced scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. ELY, M0590ITn OR VC -TOR POTENTIAL <br /> State possible vector potential necessary control: <br /> 5 . TOILET/HATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 8. PREVIOUS MRATION HISTORY <br /> 7. GENERAL SANITRTTON <br /> State any problems not previously noted: <br /> 3 . POUILATIM DEsY M, <br /> Appy. No, People per sq. mi. <br />