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1 . UWAGE <br /> Distance to Public Sewers /�` Connection necessary : Yes NoZ- <br /> Does existing septic, system comply with Ord. #549 : Yes No_ <br /> Unknown If no, explain: <br /> Descri a sept: c installation to ,be installed : <br /> 2 . WATER SUPPLY <br /> Is w ter supplied by private well : Yes No Is well rope• <br /> Yes Na State deficiency: .3 Tipp- .�' i L .ye�l '^ /�!c/E �,• <br /> Does existing or pox-posed use make this well pu lic water: Yes— <br /> No >< <br /> esNo> Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE ,y%� <br /> Licensed scavenger ' pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: ___ <br /> 4 . FI]L, MOSQUITO OR YELTOR PO PENT IAL <br /> State possible vector potential & necessary con trol :iG'��G` <br /> TQI i SET/BATH FACILITEa <br /> No. & location existing : Additional <br /> facilities needed___ <br /> 6 . PREVIOUS OPEERR�ATION RMT-0-21 <br /> 7 . GENERAL SANIJALMU <br /> State any problems riot previously rioted:����` <br /> g . POPULATION DENSITY <br /> Apex . No . People per sq. <br />