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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes Nq— <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 well : Yes No Is well proper: <br /> Yes No State deficiency : _ <br /> Does existing or porposed use make this well public water : Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information ox- comments : A-0 0 ill/ u e?re� <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: — <br /> 4 . FLY, MOSQUITO OR VIL,TQ�PsfLIMIAL <br /> State possible vector poten;inl neces6ary control : <br /> 5 . TQTLFT/BATH FACILI71. <br /> No . & location existing : __ Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION H.I=I <br /> RY <br /> 7 . GENERAL SANI'rf,�'1'IQA <br /> State any problems not previously note <br /> Appx . No . People per sq. mi._ <br /> �D 5 cam ' at, - <br /> S <br /> Uva �'i f—f' 2 ✓X A/v c.J L-/ �- 3 -a g`l <br />