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1 . SEWAGE � /q <br /> Distance to Public Sewers — Connection necessary : Yes_ No✓, <br /> Does existing septic system comply with Ord . #549 : Yes_ No✓ <br /> Unknown If no, explain : <br /> No t x is b to .) ts4c, <br /> � Sv�O-Fz c U <br /> Describe septic installation to be installed: <br /> _C'xol T l3 ¢v olrzef5 <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes _ No'/Is well proper: <br /> Yes_ No_ State deficiency: <br /> Doesxisting or porposed use make this well pubic water : Yes <br /> No - Sample of well water taken: Yes_ No— Date taken <br /> Results Additional information or comments <br /> 3 . i4V R. P FUSE <br /> License scavenger pick-up: Yes— No_ Ser vi Area No . <br /> Other pro osed disposal method: <br /> Potential oblem <br /> i <br /> 4 . FLY COR VZO ) MME TIAL <br /> State possible vector potential & nyessary control : <br /> 5 . TQTiFT/BATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . ORY <br /> 7 . ) <br /> State ar problems not previously noted: <br /> B . POPULATION DENSITY <br /> Appx . No. People per sq. mi ._ <br />